LIBRARY OF CONGRESS, 



UNITED STATES OF AMERICA. 



CLINICAL DIAGNOSIS 



BY 



1/ 
ALBERT ABRAMS, M. D. o^™. 



Professor of Pathology, Cooper Medical College, San Francisco, Cal. ; Pathologist 

to The City and County Hospital, San Francisco ; Author of " A Synopsis 

of Morbid Renal Secretions" etc. ; President of The San Francisco 

Medico Chirurgical Society (1893-1894) ; President of The 

Alumni Association of Cooper Medical College 

(1888-1889) 



THIRD EDITION, REVISED AND ENLARGED 



ILLUSTRATED 




pMAR 6 1894 



Zlcr v^svC 



fiytt 7j 



New York 

E. B. TREAT, 5 COOPER UNION 

1894 

PRICE, $2.75 




Copyright, 
By ALBERT ABRAMS, M. D., 

1890, 1892, 1894. 




TO HIS ESTEEMED FRIEND 

JOSEPH 0. HIRSCHFELDER, M. D., 

PROFESSOR OF CLINICAL MEDICINE, COOPER MEDICAL COLLEGE, 

THIS HUMBLE VOLUME IS DEDICATED, TO EXPRESS FOR 

ACTS OF KINDNESS, THE OBLIGATIONS 

AND GRATITUDE OF 



—THE AUTHOR. 



PREFACE TO THE THIRD EDITION. 



rjlHE favorable reception accorded to the previous editions, has 

induced the author to undertake the revision and enlargement 

of this work by the addition of many synoptic tables, a chapter on 

insanity, and a summary of recent methods of diagnosis. The 

original character of the work has been preserved as an index to 

or as an abstract of more pretentious works on the subject. " I have 

gathered a posie of other men's flowers, and nothing but the thread 

that binds them is mine own." 

ALBERT ABRAMS, M.D. 

Cooper Medical College, \ 
San Francisco, Jan. 12, 1894. » 



CONTENTS 



CHAPTER I. 

PAQX. 

Examination of Medical Cases — diathesis — position of the 
body — expression of countenance — examination of the 
skin — perspiration — oedema of the skin — emphysema 
of the skin — temperature of the skin 1- 9 

CHAPTER II. 

Temperature — fever — temperature and symptoms of the 
acute infectious diseases 10- 20 

CHAPTER III. 

Examination of Respiratory System — examination of the 
nose and larynx — diseases of the larynx..... 21- 27 

CHAPTER IV. 

Examination of the Thorax — inspection — palpation — men- 
suration — percussion — auscultation — succussion — asso- 
ciation of the physical signs of the lungs — physical 
diagnosis of respiratory diseases — phonograph in 
medicine 28- 59 

CHAPTER V. 

Cough — Sputum — the sputum in diseases of the respiratory 

apparatus 60- 68 

(lx) 



X CONTENTS. 

CHAPTER VI. 

FAOB. 

Examination op the Heart — inspection and palpation — 
table of thrills — percussion — auscultation — endocardial 
murmurs — diagnosis of cardiac diseases G9- 84 



CHAPTER VII. 

Examination op the Arteries and Veins — thoracic aneu- 
rism 85- 



CHAPTER VIII. 
The Pulse — sphygmography 90- 94 

CHAPTER IX. 

The Blood — microscopic examination of the blood — diseases 
of the blood 95- 102 

CHAPTER X. 

The Digestive System — examination of the oesophagus — 
examination of the stomach — chemical analysis of the 
stomach — diseases of the stomach — vomiting — exam- 
ination of the intestines — examination of the peritoneum 

— differential diagnosis of ascites and cysts of the ovary 

— examination of the faeces — examination of the liver — 
examination of the pancreas, omentum and retroperito- 
neal glands — examination of the spleen 103- 132 

CHAPTER XL 

Examination of the Genito-Urinary Organs — examination 
of the kidneys — differential diagnosis of diffused diseases 
of the kidneys — diagnosis of diseases of the bladder — 
urinary calculi — pathological concrements — the urine — 
secretions of the male generative organs — a synopsis of 
morbid urine 133 - 159 



CONTENTS. xi 

CHAPTER XII. 

PAGE. 

The Nervous System — anatomy and physiology of the brain 
and spinal cord — paralysis of the cranial nerves — 
paralysis of the spinal nerves — testing the sensibility — 
motor symptoms of irritation — reflexes — examination 
of the nerves and muscles by electricity — instantaneous 
diagnosis of nervous diseases — medical ophthalmology — 
160- 183 

CHAPTEE XIII. 

Parasites — animal parasites — vegetable parasites — bacteria 
oo. .184- 194 



APPENDIX. 

The Nervous System — examination of the mind — diagnosis 
of insanity — relation of diseases and functions to insanity 
— topography of the brain — spinal localization — diagnosis 
of nervous diseases, synoptic table of paralyses — diagnosis 
of vaso-motor and trophic diseases, and diseases of muscles 
s 197-222 

Diagnosis of Diseases of the Skin — drug exanthemata — 

..223 - 228 

Bacteriological Diagnosis — bacteriological analects 229 - 234 

Diseases of the Intestines and Peritoneum — analectic re- 
view of gastric digestion and gastric neuroses — relation of 
diseases of the stomach to other diseases 235 - 243 

The Employment of Drugs in Diagnosis 243- 247 

Recent Methods of Diagnosis. . . 247- 254 



ILLUSTRATIONS 



no. 




FA«X 


1. 


Temperature chart in variola • • • . . 


15 


2. 


Temperature chart in typhus abdominalis . . 


. 16 


3. 


Temperature chart in febris intermittens . . 


18 


4. 


Temperature chart in croupous pneumonia . • 


, 18 


6. 


Paralysis of the vocal cords 


24 


6. 


Topography of the chest (anterior view) . . 


. 29 


7. 


Topography of the chest (posterior view) • • 


30 


8. 


Microscopy of the sputum .... 


. 63 


9. 


Normal pulse traciug 


92 


10. 


Pathological sphygmographic tracings . • . 


, 93 


11. 


Microscopical examination of the blood ... 


97 


12. 


Microscopical examination of the vomit • • 


. 116 


13. 


Microscopy of the stool 


122 


14. 


Crystals of the urine 


. 145 


15. 


Casts of the urine 


157 


16. 


Side view of the human brain 


160 


17. 


Vertico- transverse section of the cerebrum . . 


162 


18. 


Transverse section of the spinal cord . . . 


. 163 


19.~ 


-23. Motor points ••••;• 17( 


1—178 


24. 


Taenia solium 


. 185 


25. 


Taenia saginata 


185 


26. 


Eggs of the oxyuris and ascaris lumbricoides • 


, 185 


27. 


Muscle trichina 


185 


28. 


Bacteria •••••••••< 


> 194 



CHAPTER L 

EXAMINATION OF MEDICAL CASES. 

In investigating a medical case the following or a 
similar plan should be pursued, the object being to make 
a thorough examination, which is facilitated by a definite 
procedure. 

Name. Age. Occupation. Date of Examination. 

Patient's history {anamnesis). 1. Family history. 2. Diseases 
of childhood. 3. Previous diseases. 4. Mode of Life. 5. Present 
Sickness (date, mode of invasion, etc). 

Objective Examination (Status praesens). 

General symptoms. 

1. Constitution (bone, muscular and fat development). 

2 Position i in bed— mode of lying; 

L. Position -j Q?t o{ be d— movements. 

3. Expression of countenance. 

4. Skin (color, perspiration, ozdema, etc)* 

5. Temperature. 

6. Respiration (frequency, type, etc). 

7. Pulse (frequency, rythm, etc). 

8. Tongue. 

Then follows the examination of special regions, beginning 
with the one presumably involved. 

Respiratory System. — 1. Nose. 2. Larynx. 3. Rythm of respi- 
ration. 4. Form of thorax. 5. Type of respiration. 6. Inspection 
of thorax. 7. Palpation. 8. Percussion. 9. Auscultation. 
10. Cough and expectoration. 

Circulatory System.— 1. Examination of the heart and large 
arteries (beginning with inspection and following with the other 
physical signs). 2. Examination of the veins. 3. Examination 
of the blood. 

Digestive System.— 1. Lips. 2. Tongue. 3. Mouth. 4. (Esoph- 
agus. 5. Stomach. 6. Intestines. 7. Peritoneum. 8. Liver. 
9. Spleen. 10. Pancreas. 11. Examination of the stomach 
contents and faeces. 

Genito-Urinary System. — 1. Examination of the kidneys, uret- 
and bladder. 2. Examination of the urine (to be made in all 

(l) 



2 MANUAL OF CLINICAL DIAGNOSIS. 

cases) ; quantity, specific gravity, reaction, color, odor, sediment; 
quantity and character by microscopical examination ; albumen 
and sugar. 

Nervous System. — 1. Examination of the head. 2. Vertebral 
column. 3. Sensibility. 4. Motility. 5. Examination by means 
of electricity. 6. Reflexes. 7. Organs of special sense. 

Diagnosis. Treatment. Event. 

Diathesis. In the examination of patients, the 
physician often generalizes the symptoms in certain 
cases, showing that the patient has some peculiar and 
specific constitutional morbid tendency. The following 
diatheses are usually referred to : 

Phthisical Diathesis.— Clubbing of the finger ends, undue curva- 
ture of the nails, red line on the margin of gums, momentary 
elevation of the skin in percussing the thorax (myoidema), flush- 
ing of the face (hectic flush) paralytic thorax and emaciation. 

Apoplectic Diathesis. — Red and congested face, short neck, 
rigidity of the arteries and obesity. 

Gouty Diathesis. — Obesity, varicose veins, oppression in breath- 
ing, deformities of the joints with local deposits of uric acid and 
atheroma of the arteries. 

Position of the Body (decubitus). — Patients with 
acute unilateral affections of the chest (pneumonia, 
pleuritis, pneumothorax) usually lie on the affected side to 
avoid pain during respiration and allow unaffected, to 
compensate the disturbed functions of affected lung. 
Patients with pneumonia occasionally lie on the unaf- 
fected side in order to avoid pain. The prone position 
may be adopted in certain cases of gastric ulcer. The 
head is thrown back in laryngeal and tracheal disease. 
In diseases of the heart and lungs when dyspnoea 
is intense, the sitting posture is adopted (orthopncea). 
Restlessness (jactitation) occurs during the invasion of 
acute disease, in delirium and acute mania. In menin- 
gitis the head is drawn backward. In affections of the 
cerebellum the entire body is often drawn to one side. In 
circumscribed affections of the cerebrum the head may be 
drawn to one side. If patient is about, the gait is an 
important sign in diagnosis, especially in affections of 
the nervous system. 

Gait in Hemiplegia (paralysis of one lateral half of body).— The 
arm hangs by affected side and the shoulder droops. At each 



EXAMIXATION OF MEDICAL OASES. 3 

step the paralyzed half is lifted to swing weak leg forward. There 
is a swinging semi-circular movement of paralyzed foot (sickle- 
walk). The shoe is worn off at the outer part of sole and toe. 

Gait in Paraplegia (paralysis of lower half of body). — Patient 
shuffles along without raising either foot from the ground (hopping 
gait). 

Gait of Lateral Sclerosis (combination of paresis, muscular 
rigidit) T and tremor). — Feet are turned inward and appear glued to 
the ground. They cross in walking and the knees are liable to 
become locked together. Weight is thrown first on one cane and 
then on the other, to lift body so as to move the feet. 

Gait of Paralysis Agitans — Tottering and trembling with a 
tendency to trot. Head bent forward and held stiffly when 
walking. 

Gait of Pseudo-hypertrophic paralysis.— Patients are children. 
Gait like the waddling of a duck. In the erect posture the 
back is excessively curved (disappears when the patient sits), so 
that a vertical line dropped from the shoulders falls behind the 
sacrum. When the patients are placed on the floor great diffi- 
culty is experienced in rising, which may however be accom- 
plished by a characteristic movement known as climbing up 
the thighs. 

Gait of Tabes Dorsalis. — Legs are flung about in an uncertain 
way, although the steps are characterized by deliberation. The 
feet are brought down with the heel projecting {flopping gait). 
Eyes are kept on the ground w T hile walking. Gait due to muscu- 
lar incoordination. 

Gait of Cerebellar Disease. — Likewise due to muscular incoor- 
dination. It is staggering like an intoxicated person. 

Gait of Cerebro-Spinal Sclerosis. — Unsteady and irregular. No 
deliberate walking in a straight line, but patient snoots suddenly 
forward or to one side (propulsion). 

Gait of Hysterical Hemiplegia.— Leg drawn along sweeping the 
ground as if lifeless. It is not swung around describing the arc 
of a circle as in ordinary hemiplegia. 

Hemiplegia almost always on the left side, and is developed 
and passes away suddenly. 

Expression of Countenance. — In Fades Hippo- 
cratica, the nose is sharp, eyes hollow, temples collapsed; the 
ears cold, skin about forehead rough, distended and parched ; 
the color of the whole face being green, black, livid or lead 
colored. Described in the words of Hippocrates, this is the 
physiognomy of approaching death. The same facial 
expression occurs in acute collapse. In typhoid fever the 
expression is dull (Fades slupida). In pneumonia the 
face has a dusky flush, in circulatory disturbances a bluish 



4 MANUAL OF CLINICAL DIAGNOSIS. 

hue. In cerebral congestion the face is full and red ; in 
acute peritonitis the countenance is pinched. Puffiness of 
the eyelids may be expressive of BrighVs Disease. 

Examination of the Skin. — 1. Changes in color. 
2. Perspiration. 3. (Edema. 4. Emphysema. 5. 
Changes in temperature. Changes in color : Pale, red, 
cyanotic, icteric, bronze skin, gray skin. Pale color. 
Physiological in those not exposed to the air. Tempo- 
rary in fear and syncope. Occurs rapidly in profuse 
haemorrhage and in collapse. Often symptomatic of a 
weakened heart. In diseases of the blood and haemato- 
poietic organs : Chlorosis, pernicious anaemia, leucaemia and 
pseudo-leucaemia. Also present in malarial cachexia, 
phthisis, carcinoma and chronic intoxication from mer- 
cury and lead. In a number of these conditions not 
only the pale hue but the color of the skin is character- 
istic, e.g. In severe anaemia : waxy lustre and yellowish ; 
Large white kidney : light wtrte skin ; Tuberculosis and 
lead intoxication : grayish white ; Chlorosis : greenish ; 
Diseases of the heart : dirty yellow ; Cachexia of Carcin- 
oma : grayish yellow. Red color may be caused by : 
1. Active dilatation of cutaneous blood vessels. 2. 
Increase in the quantity of blood. 3. Increase in the 
blood coloring matter. Universal skin redness occurs in 
fever, scarlatina and atropine poisoning. 

Local redness occurs most frequently in the face. 
Blushing on one side of the face occurs in the paralytic 
form of migraine. Hectic flush in tuberculosis. Anaemia 
attended with irritability of the heart may render face 
intensely red. 

Cyanosis. Lividity or duskiness of the skin especially 
marked in the face, lips and finger nails. It occurs 
when the blood contains too little oxygen and is sur- 
charged with carbonic acid. 

Increase of carbonic acid in the blood occurs in : 1. Disturbances 
interfering with the interchange of gases in the lungs; 2. Slowing 
of the blood current in the capillaries. To the first belong : 

a. All conditions leading to a narrowing of the air passages. 
Examples: Obstruction of larynx, compression of trachea and 
diffuse bronchitis. 



EXAMINATION OF MEDICAL CASES. 6 

b. Diseases of the lungs and surroundings. Examples; Emphy- 
sema, pleuritic exudation, and abdominal affections interfering 
with the movements of the diaphragm. 

c. Paralyses, spasms and diseases of the respiratory muscles. 
Examples: Bulbar paralysis, tetanus and progressive muscular 
atrophy. Slowing of the blood current occurs in general venous 
stasis, when from any cause the right ventricle of the heart is 
weakened, or when the large veins are compressed, just before 
their entrance into the Tight auiicle (tumors of mediastinum). 
Cyanosis is pathognomonic of miliary tuberculosis. Its occurrence 
in pneumonia is an ominous sign. Local cyanosis in the face may 
be due to extreme cold or occurring in other situations to venous 
stasis, the result <»f thrombosis or compression of the veins. The 
term morbus cxruleus is applied to extreme lividity, occurring in 
congenital malformations of the heart. 

In peritonitis, pleuritis and inflammatory affections of the 
respiratory muscles, the insufficient respirations on account of 
pain lead to dyspnoea and cyanosis. The character of the former 
and latter may be correctly diagnosed if they disappear after the 
administration of narcotics. 

Icterus. — A yellow discoloration of the skin occurring 
over the entire body. The discoloration is first manifest 
in the conjunctiva sclerx and other mucous membranes, 
and in the skin, where the epidermis is thin. 

An object glass, applied with slight pressure to the lips, will 
render the latter anaemic, and through the glass the yellow color 
will become more evident. Color varies according to the intensity 
of the icterus. It is light yellow in mild, and green, or brownish- 
green in severe forms of the affection {icterus viridis and melasicte" 
rus.) Icterus cannot be detected by gas or lamp light. In exam- 
ining the conjunctiva the presence of subconjunctival fat must 
not be mistaken for icterus. Yellow discoloration of the skin may 
develop after the use of santonin or picric acid and its salts. The 
yellow color of the skin in the, beginning of icterus is produced by 
the biliary pigments in the blood plasma. Later the cells of the 
rete malpighii imbibe the pigment, which fact accounts for the 
continuance of the icteric coloration after the immediate cause is 
removed. The symptoms peculiar to icterus are : Itching of the 
skin, minute cutaneous haemorrhages, slowing of the pulse (due 
to toxic paresis of the cardiac ganglia), yellow vision (xanthopsia) 
and nervous symptoms (delirium, coma, convulsions, etc.), due to 
cholxmia. 

Hepatogenic Icterus (icterus of resorption). Usually 
results from bile stasis, i. e., any interference with the 
entrance of bile into the intestines. Causes: Gastro-duo- 
denal catarrh, involving ductus choledochus, compression 
of the latter by tumors, or the presence in the same of 



6 MANUAL OF CLINICAL DIAGNOSIS. 

ascarides, gall stones, etc.; compression of the hepatic 
duct, closure of a number of small biliary ducts by intra- 
hepatic gall stones, and, finally, enlargement of the ven- 
ules of the liver. 

The bile is secreted under very low pressure, and even trivial 
obstructions suffice to prevent its passage into the intestines. 
After ligating the ductus choledochus in animals, sixty to seventy 
hours eiapse before the conjunctivae become colored. The dia- 
phragm in contracting subjects the liver to pressure, and is an 
active factor in forcing the bile from the smaller to the larger bili- 
ary ducts. Interference with the movements of the diaphragm 
[pleuritis diaphragmatic a dextra) is likely to cause icterus of resorp- 
tion. The immediate cause of icterus is the accumulation in the 
olood of biliary pigments. 

Hematogenic Icterus. — Caused by the destruction of 
A «fed blood corpuscles. Causes: Acute infectious diseases, 
particularly pyaemia, yellow fever and pneumonia ; after 
the use of chloroform, ether, chloral, chlorate of potash, 
etc. 

In hsematogenic icterus the bile freely enters the intestines, so 
that the stools are not discolored, whereas in hepatogenic icterus, 
the motions being usually free from bile, present a paler appear- 
ance than natural (clayey stool). In this form of icterus constipa- 
tion is present, and the fseces are highly offensive. The bile acts 
normally, both as a purgative and an antiseptic. Examination of 
the urine is of great importance in differentiating both forms of 
icterus. (See urine.) 

WeiVs Disease, also called infectious and epidemic icterus, is an 
affection characterized by a remittent type of fever, ending by 
lysis, headache, vertigo and prostration. The pulse is frequent, 
nausea and vomiting occur in half the cases, and the spleen and 
liver are enlarged. Icterus is always present. Albuminuria is 
present in about half the cases. Morbus Weilii may occur spor- 
adically or epidemically. 

Icterus Neonatorum occurs at birth and is an example of how 
sudden diminution of pressure in the portal vem will produce 
hepatogenic icterus. Normal pressure in the branches of the 
portal vein is greater than in the neighboring bile ducts ; hence a 
diminution of pressure in the former conduces to bile stasis. 

Bronzed Shin (Addison's disease). — Addison, in 1855, 
called attention to a bronze discoloration of the skin, 
associated with disease of the supra-renal capsules. This 
affection is characterized by a gray, brown, or even black- 
ish discoloration of the skin, beginning in parts exposed 
to the air (face and hands), and then involving parts nor- 



EXAMINATION OF MEDICAL CASES. 7 

mally pigmented, or diffusing itself over the entire body. 
The nails and conjunctivae remain unaffected. Circum- 
scribed pigmented spots may develop on the mucous mem- 
brane of the lips. The cause of the Bkin discoloration is 
a deposit of granular pigment in the cl-IIs of the rete mal- 
pighii. The constitutional symptoms associated with this 
disease are: Great feebleness of the muscles and heart, 
pains in the back and vomiting. It is commonest in 
young male adults, and is often complicated with phthisis 
or disease of the vertebrae. 

Grayish Discoloration of the Skin (Argyria). — The long 
continued use of nitrate of silver conduces to a deposit of 
black granules (metallic silver) in the skin. The skin, 
especially of parts exposed to the light (face and hands), 
shows the most pronounced discoloration. A similar 
deposit in the viscera causes the latter to become dark 
colored. Argyria has been observed to follow even the 
long continued local application of lunar caustic. 

Perspiration. — An increase of the sudoriparous 
secretion is called hyperidrosis, a diminution hyphidrosis, 
and an absence of sweat, anidrosis. 

Hyperidrosis may be local (hyperidrosis localis), confined to one 
side of the body ( liemidrosis) or diffused (hyperidrosis universalis). 
Universal hyperidrosis is observed in febrile diseases, tetanus, 
fever, pain, dyspnoea, collapse, and after the use of diaphoretics 
and opium. Acute articular rheumatism is characterized by profuse 
diaphoresis. In phthisis {night sweats) increased perspiration is 
frequent. In febrile diseases a fall of temperature is attended 
with sweating. Local sweating occurs in various neuroses and 
anatomical lesions of the nervous system. Anidrosis is encoun- 
tered in high continuous fever, and in affections attended by a 
large loss of water (diabetes, cholera and contracted kidney). 

Qualitative Change of the Sweat. — Colored sweat (chromidrosis) 
is observed in icteru3 (yellow sweat). Blue, green and black sweat 
are said to have been observed. Bloody sweat (hcematidrosis) is 
really caused by extravasations of blood from the cutaneous blood- 
vessels. In retarded urinary excretion urea may be excreted by 
the sweat (uridrosis), in the form of glistening white scales, which 
give the reactions of urea. 

(Edema of the Skin. — From the capillaries and 
venules of the skin and subcutaneous tissue a continuous 
transudation of fluid takes place, which, after subserving 



8 MANUAL OF CLINICAL DIAGNOSIS. 

the purposes of nutrition is taken up by the lymphatics 
and again conveyed to the blood. An abnormal accumu- 
lation of this fluid in the substance of the tissues is called 
oedema. When the fluid collects in the greater cavities of 
the body we have hydrops or dropsy. It is usual to 
describe oedema of the integumentary structures as anas- 
arca. If the effusion of liquid is general throughout the 
body, we speak of general dropsy, if limited to the peri- 
toneal cavity, it is called ascites. 

In pronounced oedema other tissues, especially the muscles, 
contain fluid. (Edematous parts are increased in size, the skin 
is pale {pressure of the fluid on the blood-vessels), smooth, shiny, 
tense and possessed of a certain transparency. Pressure with the 
finder on cedematons parts leaves a depression (pathognomonic) 
called pitting, which soon disappears. When oedema first 
appears in the feet (malleoli ), some interference with blood pres- 
sure may be assumed, if on the contrary it is first manifested in 
the eyelids, some constitutional cause (nephritis) is probable. 
(Edema is caused by one of the following conditions : 1. Venous- 
stasis (mechanical hydrops). 2. Altered or watery condition of 
the blood (hydremia). 3. Inflammation. When oedema is asso- 
ciated with cyanosis and dyspnoea it i-^ usually symptomatic of a 
non-compensated cardiac lesion. (Edema in venous stasis 
results from the distended veins, filled to repletion, being unable 
to take up the fluid normally transuded. 

(Edema with Albuminuria. — A combination of these 
symptoms is called after Richard Blight, BrighVs Dis- 
ease. (Edema in albuminuria is explained as follows : 
The endothelial cells of the small vessels do not nor- 
mally allow of the passage of any large quantity of 
plasma. If the nutrition of the endothelium is in any 
way impoverished as occurs in nephrit s owing to the 
retention in the blood of excretory products, then the 
blood-vessels become permeable and oedema results. 

(Edema with Cachexia. — (Edema without dyspnoea, 
cyanosis or albuminuria, is usually associated with a 
vitiated state of the body as occurs in anaemia, phthisis, 
carcinoma, etc. This oedema is also explained by nutri- 
tive disturbances of the blood-vessels. 

(Edema with Inflammation. — Usually local and often 
characteristic of deep-seated accumulations of pus. (Edema 
of one side of the chest is frequently present when the 
fluid in the pleural cavity is purulent. This oedema is 



EXAMINATION OF MEDICAL CASES. 9 

also called collateral oedema and results from increased 
pressure in the capillaries surrounding the area of 
inflammation. 

Emphysema of the Skin. — This signifies the pres- 
ence of air in the sub-cutaneous connective tissue. It is 
characterized by abnormal distension of the skin in 
certain regions and crepitation is felt and heard on 
palpation. Pitting is obtained on pressure over the 
emphysematous parts, but unlike oedema it disappears 
rapidly. Percussion yields a tympanitic sound. 

Two forms of cutaneous emphysema are differentiated, spon- 
taneous and aspira'ed. The spontaneous form (rare) is present 
when gas develop* from tub cutaneous extravasations of blood or 
abscesses. As pi* a ted emphysema occurs whenever air or gas 
enters the sub-cutaneous tissue either from without or within. 
As examples of the former: wounds of the neck or chest. As 
examples of origin from without: abnormal communications with 
the subcutaneous tissue from any part of the respiratory or 
alimentary tract. 

Temperature of the Skin. — With the hand applied 
to the skin of a patient, the body temperature can be 
approximately determined. Palpation of the skin is of 
value in localizing pathological processes, etc. — See 
thermo-palpation. 



CHAPTER IL 

TEMPERATURE. 

Method of Examination — The temperature of the "body may he 
taken in the axillary space, rectum, vagina or mouth. The ther- 
mometer (self-registering) must be very sensitive, compared with 
a standard one and verified. It should be divided so as to exhibit 
clearly, fifths of a degree. The vagina or rectum is preferred as 
representing more nearly the body temperature. When for 
reasons of delicacy the axillary space is selected, the patient 
should lie diagonally on the right or left side, his arm firmly 
compressing the thermometer, whichremains in position for at 
least ten minutes. When the rectum is selected five minutes will 
suffice. In the rectum, temperature is about 1° F. higher than in 
the axilla. Before introducing the thermometer into the rectum 
the bulb is oiled. On the continent of Europe temperature is 
measured with the scale of Celsius, also called centigrade (freezing 
point 0°, boiling, 100°) whereas in England and in the United States 
the Fahrenheit scale is employed (freezing 32°, boiling, 212°). 

The scale of centigrade is reduced to that of Fahrenheit by 
multiplying by 9 and dividing by 5 ; that of Reaumur (Kussia anil 
Sweden) to that of Fahrenheit by multiplying by 9 and divid- 
ing by 4; and when above zero in either case add 32. Fahren- 
heit is reduced to either of the preceding by reversing the 
process. C 100° x9 = 900-f 5 = 180 + 32=212°F. ; It. 80° x 9 = 720 + 
4= 180° + 32 = 212°F. The following formula is also employed : 

N°C.=f n° R.=f n°+32*F. 



o. 


R. 


F. 


36* 


28.5* 


96.8* 


37* 


29. 6° 


98 6* 


38* 


30.4° 


100.4* 


39* 


31.2° 


102.2* 


40° 


32.0* 


104.0* 


41° 


32.8° 


105.8* 



Normal Temperature.— Tn the axilla this varies 
between 86.2° C. (97.1° F.) and 37.5° C. (99.5° F.). The 
temperature is highest (daily maximum) in the evening 
between five and eight, and lowest {daily minimum) in 



(10) 



PEVER. 11 

morning between two and six o'clock. The difference 
between minimum and maximum is about 1° C. (in rare 
instances 2° C). Slight temporary elevations of tempera- 
ture occur after a full meal (fever of digestion), physical 
exertion and hot baths. A continuous elevation of tem- 
perature occurs in fever. 

Subnormal Temperature. — This is observed in 

febrile conditions at the crisis and the normal tempera- 
ture is again attained after one, two or three days. 
Observed in collapse it is accompanied by diminished 
cardiac activity, increased pulse frequency, paleness of 
the skin and general weakness. It is further observed 
after haemorrhages and in the course of chronic, cardiac 
and pulmonary affections. Permanent subnormal tempera- 
ture (rare) may be encountered in wasting diseases and 
insane patients. 

FEVER. 

Fever is not only characterized by a continuous eleva- 
tion of temperature, but by a symptom complex, the 
result of increased tissue metamorphosis and functional 
disturbances of all the organs. Fever may be experi- 
mentally produced by the introduction of septic or aseptic 
matter into the circulation. In infectious diseases the 
febrile temperature is believed to be caused by the direct 
action of micro-organisms upon the nerve centres, or by 
the action of a poison which they develop within the body. 
It is now believed by many that elevation of temperature 
attending acute infections is salutary. The growth of the 
tubercle bacillus ceases at a temperature above 41° C. 
(105.8° F.), and the spirilla of relapsing fever disappear 
at the close of each paroxysm when the temperature 
reaches 42° C. (107.6° F.). The lesions peculiar to pro- 
longed fever are distributed among the viscera and consist 
of granular fatty degenerations of the cellular elements. 

Symptoms of Fever. — Usually the pulse rises syn- 
chronously with the temperature, and averages an increase 
of ten beats for every degree above 98° F. 



12 MANUAL OF CLINICAL DIAGNOSIS. 

When the pulse frequency is more than 160 per minute in fever 
the prognosis is bad. The respirations in fever are increased, there 
is loefl of appetite, increased thirst, digestive disturbances, and 
diminished secretion of a highly colored urine, with an increase of 
the solid constituents. The pulse is very slow in meningitis and 
rapid in scarlatina; in uncomplicated typhoid, pulse frequency is 
not usually more than 110. Herpes of the lips and nose absent in 
typhoid and present in pneumonia and meningitis. 

CLASSIFICATION OF TEMPERATURE. {Wunderlieh). 

36° C. (96.8° F.) Temperature of collapse. 

37 5° - 33° C. (99.5° - 100 4° F.) Sub-febrile temperature. 

3S°-38.5° C. (100.4°- 101.3° F.) Slight fever. 

39° C. (102.2° F.) morning; 39.5° 0. (103.1° F.) evening. 

Moderate fever. 
39.5° 0. (103 1° F.) morning; 40.5° C. (104.9° F.) evening. 

Considerable fever. 
Over 39.5° 0. (10 1.1° F.) morning; Over 40.5° C. (104.9° F.) 

evening. High fever. 
Over 41.5° C. (106.7° F.) Hyperpyrexia. 

As the temperature rises above 40° C. (104° F.) the gravity of the 
disease rapidly increases. In certain affections of the nervous 
system (tetanus and hydrophobia) the temperature may reach 43°- 
45° C. (110°-113° F.), and in a few cases this temperature has been 
exceeded. 

Daily Variation of Temperature in Fever. — 

Analogous to the daily variations in health there is usu- 
ally in fever an increase of temperature in the evening 
(exacerbation) and a fall in the morning (remission). 
When this is reversed we have the typus inversus (usually 
in phthisis). 

Types of Fever. — Febris continua; when a daily dif- 
ference of not more than 1° C. (1.8° F.) exists (tempera- 
ture usuallv high). Febris remittens: a daily difference 
of not more'than 1.5° C. (2.7° F.). 

Febris Intermittens: The fever usually lasts only a few 
hours fever paroxysm) whereas during the rest of the 
day no fever is present (apyrexia). 

Febris Recurrens: A continuous fever, lasting from 5 to 
7 days, followed by apyrexia from 5 to 8 days; then tem- 
perature again rises and lasts from 5 to 7 days, ending by 
crisis. 



TEMPERATURE OF INFECTIOUS DISEASES. 13 

Febrile Stages.— Stadium incrementi: the stage of 
rising temperature. Fastigium: the stage of highest tem- 
perature. Stadium decrementi: the stage when the tem- 
perature falls. 

When the temperature falls quickly we speak of the fever as ter- 
minating by crisis. When the fall is slow, occupying several days, 
the termination is by lysis. A high rise of temperature preceding 
crisis is called perturbatio crilica. Crisis is usually accompanied 
with profuse perspiration and diminished pulse frequency. Febris 
hectica is a form of the remittent type in which the exacerbations 
are very high, whereas the remissions go below normal. Hectic 
fever is observed in purulent and septic conditions. 

Stages of Exanthematous Diseases: 1. Incuba- 
tion : the period from the exposure to the infection, to the 
outbreak of the disease. 2. Prodromal stage: time from 
the beginning of the fever to the appearance of eruption. 
3. Eruption. 4. Defervescence. 

Character of the Fever. — Febris stupida : when the 
patient is apathetic and very quiet. Febris versatilis: 
slight delirium, twitching of the tendons of the wrist 
(subsultus tendinum) and picking at the bed-clothes (floe- 
citatio). These signs are very unfavorable. Fever is 
further classified as dynamic or sthenic (full pulse, flushed 
skin, active delirium) and adynamic or asthenic (pulse 
feeble, pale skin, low delirium and great prostration.) 



TEMPERATURE AND SYMPTOMS OF THE 
ACUTE INFECTIOUS DISEASES. 

MEASLES— MORBILLI. 

Incubation, 10 days. Prodromal stage, 3 days, attended 
by running at the nose and eyes, sneezing and coughing. 
Slight fall of temperature on the 2d or 3d day. Eruption 
(beginning on the face) on the 3d or 4th day, when 
temperature reaches its highest point. Continuous fever 
from the 4th to the 7th day. Crisis of the 7th day. 
Desquamation, 14 days, with very annoying itching. 
Eruption appears first on the face, then spreading to the 
trunk, and from the trunk to the limbs. It consists of 
elevated red patches, which tend to assume a circular 
outline; between these patches the skin is of natural color. 



U MANUAL OF CLINICAL DIAGNOSIS. 

Complications. — Pneumon'a, bronchitis and pleuritis. 
Sequelae. — Chronic cough, otorrhcea, enlarged lymphatic 
glands, etc. 

SCARLET FEVER— SCARLATINA. 

Incubation, 2 to 4 days. Prodromal stage, 1 to 2 days, 
commencing with a chill and rapid rise of temperature. 
Eruption on 2d day, with increased temperature. From 
the 4th day on, temperature falls by lysis. Desquamation 
from 4 to 14 days. Eruption presents a bright uniform 
redness, similar to that of a boiled lobster. It appears 
first on the thorax, abdomen, neck or back. In malignant 
forms of the disease eruption comes out late, and is either 
indistinct or cWk and livid. 

Diagnosis. — Tongue red and papillae prominent (straw- 
berry tongue), angina, and very rapid pulse. 

Complications. — Nephritis with dropsy (usually between 
the tenth and twentieth day of disease), cerebral symp- 
toms (in children), diphtheria, oedema of glottis, etc. 

Sequelae. — Boils, swelling of lymphatic glands, diarrhoea, 
otitis, etc. 

Mortality in epidemics, 50 to 60 per cent.; otherwise 
about 15 per cent. 

SMALL-POX— VARIOLA. 

Incubation, 10 to 13 days. Prodromal stage, 2 to 
5 days, commencing with a chill and high fever. 
Eruption on 2d or 3d day, with diminution of fever 
lasting to the 9th day. From the 9th to the 11th day 
temperature again rises (fever of suppuration), and is 
remittent in type. Fever ends by lysis. Eruption in 
most cases appears first on the neck and face, as red 
papules, which feel like shot embedded under the skin. 
After a day or two the papules becomes vesicular, then 
purulent. The pustules may run into one another in 
grave cases (confluent small-pox) or remain isolated (dis- 
crete small-pox). A depression in the centre of the pustule 



TEMPERATURE OF INFECTIOUS DISEASES. 



15 



is present (umbilicatioii). Eruption may also affeat 
mouth. In severe forms of the disease haemorrhages are 
seen under the skin, as well as inside the pustules 
(hemorrhagic small pox). During invasion severe lumbar 



Fig. 1. Temperature Chart in Variola 



<to,o 


iipis 


lliiilll 


40,0 
89,0 


B|SBBi 


mmmm 


88,0 


!JLili!™ii! 


wmmmi 


87,0 




HBiiiii 


C6J) 







105.8 
104.0 
102.2 
100.4 
98.6 
96.8 



2 



I* 
o 






pain is characteristic, 
is about 4 per cent, 
per cent. 



The mortality in discrete variola 
in confluent small-pox about 50 



VARIOLOID. 

This is modified small-pox, occurring in a person' par- 
tially protected by vaccination. Usually mild. 

Incubation and prodromal stages are the same as in 
variola, although lighter. Fever of suppuration is absent, 
Desquamation begins on the Cth or 10th day. Eruption 
may resemble that of variola, although it often consists 
of only a few abortive papules, without vesication or pus- 
tulation. 



CHICKEN-POX— VARICELLA. 

Prodromes usually absent. Fever begins with a chill 
and lasts until drying of the exanthema (2 to 4 days). 



16 MANUAL OF CLINICAL DIAGNOSIS. 

Eruption is vesicular, preceded by red spots. This affeo- 
tion is not prevented by vaccination. 

TYPHUS FEVER. 

Incubation, 3 to 21 days. Prodromes absent. Begins 
with a chill and rapid rise of temperature, which is con- 
tinuous from 13 to 17 days, with slight remissions at the 
end of the 1st week; and ends by crisis, with perturbatio 
critica. Eruption appears from 4th to 7th day and looks 
like that of measles. The spots (mulberry rash) are of a 
dark tint and very numerous on the trunk and extremities 
(rare upon the face). The mortality is about 25 per cent. 

TYPHOID FEVER — TYPHUS 
ABDOMINALIS. 

Incubation, 7 to 21 days. Prodromal stage lasts about 
a week, and is accompanied by a feeling of malaise. In 
the 1st week temperature rises slowly, reaching its highest 
point in from 4 to 7 days. Then febris continua until the 
3d week in the mild and the 5th week in the severe forms. 
Then, while the evening temperature is still high, the 
morning temperature begins to fall and the fever ter- 
minates by lysis, which, in mild cases, is about the 4th 
week. 

Temperature chart In Typhus abdommaTIs, 




Fig. 2. 



Diagnosis. — Tumefaction of spleen, epistaxis, diarrhoea? 
ileo-csecal tenderness and gurgling, distension of abdomen 
(tympanites') and nervous disturbances (headache, delir- 



TEMPERATURE OF INFECTIOUS DISEASES. 17 

ium, somnolence). Eruption (absent in 12 per cent, of 
cases) appears about the 7th day or later,' and con- 
sists of small red spots, similar to flea bites. The spots 
are usually confined to the abdomen and chest, and dis- 
appear on pressure. Later in the disease an eruption of 
minute transparent vesicles (sudamina) may appear. 
The mortality is about 18 per cent, in hospital and 10 to 
12 per cent, in private practice. 



RELAPSING FEVER— FEBRIS 

RECURRENS. 

Incubation, 5 to 7 days. Prodromal stage usually 
absent. Begins with a chill and sudden rise of tempera- 
ture. Continuous fever 5 to 7 days, and then termination 
by crisis. Following crisis no fever (apyrexia) from 5 to 
8 days ; after this the temperature again rises as at first, 
but is of shorter duration. After a period of 7 days there 
may be a third attack, lasting however from 2 to 3 days 
only. Diagnosis : Enlargement of the spleen, and the 
presence in the blood of spirilla (see Blood). The mortality 
in private practice is about 20 per cent. 



MALARIA— FEBRIS INTERMITTENS. 

Incubation, 7 to 21 days. Prodromal stage not 
marked. There is a chill followed by rapid rise of 
temperature lasting but a few hours, and terminating 
by crisis with profuse perspiration. The period between 
the termination of one attack and the beginning of 
another is called intermission or apyrexia. When the 
fever recurs every day it is called quotidian ; every 
second day tertian and every third day quartan inter- 
mittent fever. Two attacks of fever occurring on the 
same day is spoken of as febris intermittens duplicata. 
When the second attack of fever occurs at an earlier 

M. C. D. 2 



18 



MANUAL OF CLINICAL DIAGNOSIS. 



hour of the day than the first attack, we speak of febris 
intermittens anteponens, when at a later hour, post-ponens. 



Fig. 3. Temperature Chart In 
Febris Intermittens. 



Fig. 4. Temperature Chart in 
Croupous Pneumonia. 




Diagnosis. — Periodicity of the febrile attacks, enlarge- 
ment of the spleen, specific action of quinine and the Plas- 
modium malarias in the blood. When an intermittent 
fever does not yield to quinine, endocarditis, latent tuber- 
culosis or pus somewhere in the organism may be sus- 
pected. 

PNEUMONIA CROUPOSA. 

Begins with a severe chill and sudden elevation of 
temperature. The fever is continuous and ends by crisis 
on the 3d, 5th, 7th or 9th day. When the fever persists, 
empyema or the termination of the pneumonia in abscess of 
the lung, gangrene or tuberculosis may be suspected. 

Diagnosis. — Dullness, bronchial respiration, crepitant 
rales, rusty sputum and pneumococci. Mortality 8 to 20 
per cent. Pneumonias in drunkards are grave. 



ERYSIPELAS. 

Incubation, 1 to 8 days. Begins with a chill and high 
temperature. Inflammation of the skin on the 1st or 



TEMPERATURE OF INFECTIOUS DISEASES. 19 

2d day. Continuous fever during the time erysipelas 
spreads. Temperature falls when spreading ceases. 

Complications. — (Edema of the glottis, bronchitis, 
pneumonia, endocarditis and cerebral erysipelas (extends 
to brain from facial vein). 

Acute Articular Rheumatism. — The tempera- 
ture remains steady after the symptoms develop, with 
evening exacerbations and morning remissions when the 
joint affection is yielding, but rises when new joints 
become involved. 

Diagnosis. — Tumefaction, redness and tenderness of 
the joints. Affection yields to salicylic acid, salol or 
antipyrin. 

Complications. — Pericarditis (usually between the 
4th and 14th day), endocarditis (in about 20 per cent, 
of the cases), bronchitis, pleuritis, etc. 

Diphtheria. — Temperature is atypical and for the 

prognosis of little value. 

Diagnosis. — A white or gravish exudation on the ton- 
sils, uvula and soft palate. Mucous membrane of nose, 
larynx or bronchi may be involved in severe cases. 
Exudation which is not easily removed leaves a bleeding 
raw surface which is soon covered with a new exudation, 
Submaxillary and cerv c:il glands enlarged and tender. 
Weakness and prostration are prominent symptoms. 

Sequelae. — Profound anaemia, nephritis and post 
diphtheritic paralyses (about 2 to 3 weeks after recovery). 

Prognosis. — Always grave. In a mild epidemic aver- 
age mortality 5 per cent., in a severe epidemic 33 per 
cent. 

Acute Miliary Tuberculosis. — Temperature is 

atypical, although the typus inversus is frequent. 

Diagnosis. — Cyanosis, dyspnoea, crepitant rales without 
dullness on percussion and choroid tubercles seen with 
ophthalmoscope. 

Cerebro- spinal Meningitis. — Temperature may 
be continuous or remittent, and is of long duration. 



20 MANUAL OF CLINICAL DIAGNOSIS. 

Diagnosis. — Somnolence, stiffness of the neck muscles, 
vomiting, retracted abdomen, slow pulse, pupils usually- 
contracted, eruption (absent in one-half the cases) con- 
sists of petechial spots of extravasated blood. 

Prognosis. — The mortality varying with the epidemic 
is from 20 to 75 per cent. The disease is less fatal in 
children than adults. 

Syphilis. — Incubation (3 to 4 weeks). Primary stage; 
chancre and swelling of neighboring lymph glands. 
Secondary stage (9 to 11 weeks after exposure to infec- 
tion) ; usually begins with a chill and fever (fever of 
eruption) of a remittent type. Tertiary stage ; develop- 
ment of gummata. 

Diagnosis of the Exanthema. Pain and itching not 
troublesome, copper color, polymorphism (papules mac- 
ules, pustules, scales, etc. co-exist), tendency to circular 
form of the patches and eruption shows a predilection for 
certain parts ; around the forehead (corona veneris) palm 
of the hand, sole of the foot, etc. 



CHAPTER III. 

EXAMINATION OF THE RESPIRATORY 
SYSTEM. 

EXAMINATION OF THE NOSE AND LARYNX. 

THE NOSE. 

Rhinoscopy. This is the art of inspecting the nasal 
cavities and naso-pmiryngeal space, it is divided into 
anterior and posterior rhinoscopy. In anterior rhinoscopy 
the view obtained even under favorable conditions is 
limited, and usually comprises the anterior portions of 
the lower and middle turbinated bones, with the cartilagin- 
ous portion of the septum. 

Posterior Rhinoscopy. The rhinoscopic image is made 
up of the following : vomer or nasal septum, floor 
of nose, superior meatus, middle meatus, superior turbi- 
nated bone, middle turbinated bone, inferior turbinated 
bone, pharyngeal orifice of Eustachian tube, upper por- 
tion of Rosenmuller's groove, glandular tissue at vault of 
pharynx and posterior surface of velum. 

The nasal cavities are in direct communication with other cavi- 
ties situated in the bones of the skull ; these are the antra of High- 
more, situated in the body of the superior maxillary bone and com- 
municating with the nasal cavities by an opening in the middle 
meatus \ frontal sinuses situated between the two tables of the frontal 
bone with an opening in middle meatus, and finally the sphenoidal 
cells or sinuses, situated in the body of the sphenoid bone with small 
openings in the superior meatus. Examination of the nasal cavities 
is absolutely necessary in diagnosis as many neuroses owe their 
origin to nasal anomalies, this is notably the casein asthma where 
the paroxysms are found to be associated with nasal polypi and 
with catarrh of the naso-pharyngeal mucous membrane. "Running 
from the nose" is a symptom during the invasion of measles. 
Fetor from nose {pzxna) may be distinguished from fetor due to 

(21) 



22 MANUAL OF CLINICAL DIAGNOSIS. 

lung gangrene, carious teeth, etc., by testing the breath while the 
mouth and nostrils are closed alternately. Difficulty in breathing 
through the nose in infancy {snuffles) may be due to syphilis. 
In bleeding from the nose (epistaxis), it must be remembered 
that the blood may be swallowed or accumulate in the throat and 
thus simulate hsematemesis or haemoptysis. 



THE LARYNX. 

Anatomy and Physiology. The larynx is situated between the 
upper border of the 3d, and lower border of the 6th, cervical 
vertebra. Daring respiration, phonation and deglutition, it rises 
and falls. In stenosis of the larynx the rise and fall are exaggerated. 
Widening of the vocal chink (abduction of vocal cords) is effected 
by the posterior crico- arytenoid muscle which also turns the 
processus vocalis of the arytenoid cartilage outward. Closure of 
the vocal cords (adduction of vocal cords) is effected by the 
lateral crico-aryfenoid and inter- arytenoid (transverse and oblique) 
muscles. Tension of the vocal cords is maintained by the crico- 
thyroid and thy ro- arytenoid muscles, the actual muscles of the vocal 
cords. The nerve supply is from the vagus with motor branches 
from the accessorius. The superior laryngeal nerve innerv it^s the 
crico-thyroid muscle and muscles of epiglottis (motor fibres). It 
also supplies the mucous membrane of the larynx (sensory fibres). 
The inferior laryngeal nerve (recurrent laryngeal) supplies all the 
other muscles of the larynx not supplied by the superior laryngeal 
nerve. This nerve curves backward around the subclavian artery 
on the right side and around the arch of the aorta on the left side 
and passes upward in the groove between the trachea and 
oesophagus, entering the larynx behind the articulation of the 
inferior cornu of the thyroid cartilage with the cricoid. 

Laryngoscopy. — An examination with the laryn- 
goscope reveals in a normal case the following structures : 
1. Epiglottis. 2. Glosso-epiglottic ligaments which con- 
nect tongue with epiglottis. 3. Ary-epiglottic folds with 
the cartilages of Wrisberg. 4. Arytenoid cartilages, 
cartilage of Santorini, sinus Morgagni. 5. True and false 
vocal cords, the latter are parallel to and above the former. 
The true vocal cords are divided into two parts, the 
anterior part (ligamentous) extends to the apex of the 
processus vocalis, the posterior part, from the apex to 
the base of same. The anterior part of the glottis 
is called Glottis phonatoria, the posterior part, Glottis 
respiratoria. The laryngeal image, being a reflected one, it 
is reversed. 



EXAMINATION OF LARYNX. 23 

Auto-Laryngoscopy. — The use of this method by the student 
will enable him to attain proficiency in laryngoscopy quicker 
than by any other method of practice. Let the student seat him- 
self beside a table upon which, at his left, is placed a lamp a little 
behind his head, and the center of the flame on a level with his 
eyes. In front of him is fixed an ordinary laryngeal reflector 
held in some kind of stem, and side by side with it a small toilet 
mirror. The light from the lamp is reflected on the fauces, the 
protruded tongue is grasped between the folds of a towel and the 
laryngeal mirror introduced in the usual manner and the image 
is seen in the toilet mirror. 

The laryngeal mucous membrane is pale in anaemia ; red in acute 
and grayish-red in chronic laryngitis. Swelling of the laryngeal 
tissues occurs in catarrh, oedema and deep-seated inflammation. 
Ulcers may be caused by catarrh (rare), tuberculosis, syphilis, 
carcinoma and lupus. Exudations, cicatrices, tumors and paral- 
ysis of the vocal cord may also be detected by the laryngoscope. 

Voice. — 1. Open and closed nasal voice. The former occurs 
when closing of the posterior nares is impossible, as in paralysis 
or ulcerative destruction of the soft palate. The latter occurs in 
obstruction of the nose, e. g. polypi and catarrh. 2. Hoarse voice, 
in various affections of the larynx. 3. Want of voice (aphonia) in 
functional and organic affections of the larynx. Intermittent 
aphonia is usually hysterical, it begins and disappears suddenly, 
and the cough may be clear. 4. Bass voice, in destruction of the 
vocal cords. 5. Diphlhonia in polypi of the vocal cords. 



PARALYSIS OF THE VOCAL CORDS 

During inspiration the true vocal cords separate, coming 
together again during expiration. In the act of singing the vocal 
cords come in almost immediate contact ; and in laughing and 
coughing they intermittingly strike against each other. 

Paralysis of the Recurrent Laryngeal. Leads to paraly- 
sis of the muscles supplied by this nerve. If double- 
sided (rare), the vocal cords are immovable in the half- 
way position in phonation and respiration. When the 
nerve is paralyzed on one side the healthy vocal cord in 
respiration moves outward, while in phonation it 
approaches the affected cord by crossing of the arytenoid 
cartilages. 

Symptoms. Aphonia without dyspnoea. 

Paralysis of Individual Branches. — Paralysis of 
{he Posterior Crico-arytenoid Muscle. The vocal cord can 
not be moved outward in respiration. In paralysis of 



24 



MANUAL OF CLINICAL DIAGNOSIS. 



both cords there is only a narrow space for air to enter 
the larynx. 

Symptom. Pronounced inspiratory dyspnoea. 

Paralysis of the Inter -arytenoid. In phonation there 
remains an open triangle iii the posterior part of the 
glottis. 

Paralysis of the Thyro- arytenoid. The vocal cord during 
phonation is not sufficiently tense, and it is bowed out- 
ward with its free edge concave. 



Fig. a. 



Fig. 5. a. Paralysis of the crico-arytaenoideus posticus ; posi- 
tion of inspiration, b. Paralysis of the inter-arytsenoideus; 
phonation. c. Paralysis of the thyro arytaenoideus; phonation. 
d. Paralysis recurrent laryngeal on both sides; respiration and 
phonation. e. Paralysis of the thyro-arytienoidei and inter- 
arytaenoidei muscles. 

Paralysis of the Adductors (lateral crico-arytenoid and 
inter-arytenoid). The glottis remains open during phon- 
ation as a large triangle. Paralysis of the lateral crico- 
arytenoid alone, gives the glottis a lozenge shape. 

Paralysis of the Superior Laryngeal Nerve. The voice is 
deeper because the crico-thyroid muscles which render 
the vocal cords tense are paralyzed. When the finger is 
placed between the thyroid and cricoid cartilages they 
are no longer approximated, as is the case normally 
when an attempt is made to produce high tones. There 
is also anxsthesia of the laryngeal mucous membrane 
extending down to the vocal cords. 

Paralysis of the muscles of the larynx may be myopathic or 
neuropathic, according to whether the paralysis is due to affections 
of the muscles or nerves. According to " the functions of the 
muscles of the vocal cords, we have paralysis of respiration, 



DISEASES OF LARYNX. 25 

phonation and ccmhined paralysis. The posterior cricoarytenoid 
muscles are concerned in the rirst form, their ohject being to sep- 
arate the vocal cords during inspiration, thus allowing air to 
enter the lungs. All the other laryngeal mu&chs are concerned 
in phonation and their involvement leads to paralysis of phona- 
tion, whereas a combination of both conduces to combined paralysis. 

The following are some of the causes of paralysis: 1. Affec- 
tions of the central nervous system (lesions of the medulla, pons 
and cerebrum). 2. Compression of the vagus or its branches 
(tumors, aneurism, pericarditis, pleuritis, enlarged bronchial 
glands, etc). 3. Neuroses (hysteria and epilepsy). 4. Reflex 
paralysis. 5. Toxic (lead, opium, belladonna, etc). 6. Infec- 
tious diseases (diphtheria, typhoid fever, variola, etc). 7. Dis- 
eases of the larynx. 

Palpation, Percussion and Auscultation of Larynx. — If the fingers 
are placed lightly on the larynx while speaking a peculiar vibra- 
tion (laryngeal fremitus) is communicated to them, which is 
equally strong on both sides. In laryngeal paralysis, laryngeal 
fremitus is diminished or absent. Internal palpation of lamyx is 
of great value in determining the presence of foreign bodies and 
oedema of the glottis. Percussion of the larynx gives a tympanitic 
sound, auscultation gives loud tubal respiration, called ' laryngeal 
respiration* 



DISEASES OF THE LARYNX. 

Acute Laryngitis . — Laryngoscopical examination. 
Hyperemia (diffused or circumscribed) swelling of 
mucous membrane, and at times superficial erosions. 

Diagnosis. Cough, expectoration, hoarseness, aphonia, 
tickling in the throat and slight pain in swallowing. 

Chronic Laryngitis. — Laryngoscopical examination. 
Mucous membrane of a bluish-red color, and thickening 
of affected parts. Vocal cords occupied by nodular 
eminences. (Chorditis tuber osa). Erosions. 

Diagnosis. Voice readily fatigued and from hoarse- 
ness it may pass over to aphonia, slight cough and 
expectoration and morbid sensations in the larynx 
(pressure, dryness, tickling, etc). 

Laryngitis Diphtheritica. — (Laryngeal croup). 
Laryngoscopical Examination (opportunities are rare). 
Fibrinous exudation. 

Diagnosis. Stenosis of the larynx (in — and expiratory 
dyspnoea and excessive activity of the respiratory mus- 



26 MANUAL OF CLINICAL DIAGNOSIS. 

cles), barking, brassy cough, cyanosis and stupor (carbonic 
acid intoxication). Fever usually moderate, unless 
inflammation extends to trachea and bronchi. 

A distinction must be made between primary and diphtheritic 
croup which resemble each other. 

Primary Croup is . 1. A local disease. 2. Begins in larynx. 3. 
Pharynx slightly affected. 4. Neither contagious nor infectious. 
5. Not epidemic. 

Diphtheritic Croup is, 1. A constitutional disease. 2. Begins in 
the fauces. 3. Pharynx extensively affected. 4. Contagious and 
infectious. 5. Epidemic. 

False Croup (catarrhal laryngitis) may be confounded with true 
croup (croupous laryngitis). The furmer begins suddenly in 
perfect health, whereas in true croup, cough, hoarseness, fever and 
angina precede the attack. Dyspnoea when present in false croup 
is of short duration, and we find no diphtheritic throat deposits. 

(Edema of the Glottis. — -Laryngeal examination. 
Swelling of the mucous and sub-mucous tissues, 
especially marked in the epiglottis and ary-epiglottic 
folds. 

Diagnosis. Dyspnoea is very great and very sudden. 
First it is inspiratory, but soon becomes inspiratory and 
expiratory. Swelling is distinctly felt by the examining 
finger. 

Laryngeal Tuberculosis. — Occurs as a complica- 
tion in phthisis pulmonalis in about 30 per cent, of the 
cases. 

Laryngoscopical Examination. The first manifestation 
is pyriform thickening of the mucous membrane covering 
arytenoid cartilages. Later, tubercles are seen in the 
mucous membrane as small yellowish-white spots (second 
stage). The third stage is the stage of fully developed 
ulceration. Phthisical ulcers are broad, shallow, irregular, 
gray in color, and essentially of slow progress. The 
exudation from the ulcers contains the tubercle bacillus. 

Diagnosis. Fever, pulmonary tuberculosis, hoarse- 
ness, aphonia, pain in deglutition and demonstration of 
the bacilli. 

Laryngeal Syphilis. — Laryngoscopical examination. 
In the early stages the mucous membrane is of a rose-red 
color (syphilitic laryngitis). Later stages, circumscribed 



DISEASES OF LARYNX. 27 

infiltrations or diffuse gummy deposits which rapidly 
degenerate (characteristic) leaving ulcers, which are 
deeply excavated with sharp cut edges, yellow purulent 
discharge, and rapidly destructive. 

Syphilitic ulcers are frequently found on the epiglottis. 

Diagnosis. History of syphilis and other symptoms of 
this affection. Successful results from antisyphilitic 
treatment. Syphilitic affections of the larynx are usually 
painless, and may result in dangerous adhesions, cicatri- 
zations and stenosis. 



CHAPTER IV. 
EXAMINATION OF THE THORAX. 

Topography of the Chest. — For localizing disease 
and defining the situation of organs, the chest is region- 
ally divided as follows: 

Anterior regions. — 1. Supra-clavicular, triangular 
shaped space above the clavicle containing the apex of 
lung which rises from \ to 1| inches above the clavicle. 

2. Infra- clavicular, extends from clavicle to 3d rib. 

3. Supra-sternal (jugular fossa), hollow space above 
notch of sternum and bounded on either side by the 
sterno-cleido-mastoid muscle. 4. Sternal, occupied by 
the sternum. 

Lateral Regions. — 1. Axillary, bounded by the 

anterior and posterior axillary lines. 

Posterior Regions.— 1. Supra-scapular, situated 
above scapula and contains the apex of lung which 
rises to 7th cervical vertebra. 2. Infra-scapular, below 
scapula. 3. Inter-scapular, between the scapulae and 
divided into right and left by vertebral column. Contain 
on both sides ; lung, bronchi and bronchial glands ; 
opposite 3d dorsal vertebra (2d rib in front), bifurcation of 
trachea occurs. Left inter-scapular region also contains 
oesophagus, and from 4th dorsal vertebra downward, the 
descending aorta. 

When exactness is required in localization, measurements may 
be taken from definite anatomical landmarks. 

The breadth of thorax is determined by the following 
perpendicular lines: 

1. Median, drawn through the middle of sternum. 

2. Sternal (right and left), drawn along borders of 
sternum. 

(28) 



EXAMINATION OF THE THORAX. 



29 



3. Mammary, drawn through nipple which lies usually in 
the 4th inter-costal space 4 inches from the sternal border. 

4. Parasternal, between mammary and sternal lines. 

5. Anterior Axillary, from the lower border of pectoralis 
major. 

6. Posterior Axillaiy, from lower border of latissimus 
dorsi. 

7. Middle Axillary, between anterior and posterior 
axillary lines. 

8. Scapular, from inferior angle of scapula. 

9. Costo-arlicular Line, from stcrno-clavicular articula- 
tion to tip of 11th rib. 

Landmarks. — Top of sternum is on a plane with the 2d dorsal 
vertebra. Angle of Louis is a bony } rominence at the union of 
manubrium wiih the body of the sternum and represents the 2d rib 
(useful in counting the ribs). Sibson's furrow is at the lower 
border of pectoralis major. Harrison's furrow is at the level of 
xiphoid process and corresponds to normal attachment of the 
diaphragm. Inferior angle of scapula is situated at about the 7th 
rib. The Fossa of Mohrenhrim, is a depression under the clavicle 
in the outer part of the infra-clavicular region between the pector- 
alis major and deltoid muscles. 




Fig. 6. a. Upper boundary of rfcht and left lung. b. Lower 
boundary of right and left lung and upper border of absolute liver 
dullnesson right side. c. Lower boundary of hepatic dullness. 
d. Parasternal line. e. Mammary line. f. Splenic dullness. 



30 



MANUAL OF CLINICAL DIAGNOSIS. 



g. Lower boundary of distended stomach. M. Auscultation of 
mitral valve, m. Anatomical position of mitral valve. 
A. Auscultation of aortic valves. T. Auscultation of tricuspid 
valve, t. Anatomical position of tricuspid valve, jfi a p P. 
Anatomical position of aortic and pulmonary valves and 
auscultation of Litter. 1. Right superior interlobar fissure, 
showing boundary line between the upper and middle lobes of 
right lung. 2. Kight inferior interlobar fissure. 3. Left inter- 
lobar fissure ending in the mammary line at the 7th rib. 




Fig. 7. 

Fig. 7. a. Upper boundary of right and left lung. b. Lower 
boundary of right and left lung. c. Lower boundary of liver, 
d. Scapular line. 1. Right and left interlobar fissures; the 
former dividing into superior (2) and inferior (3) interlobar 
fissures. 

Methods of Physical Diagnosis. — 1. Inspection. 
2. Palpation. 8. Mensuration. 4. Percussion. 5. Aus- 
cultation. 6. Succussion. 

Phonometry, plegaphony and thermo-palpation are auxiliary 
methods of diagnosis. Phonometry is a method of examination 
consisting in the applica'ion of a tuning-fork to determine the 
physical condition of the thoracic organs. When the handle of a 
tuning-fork after being struck is applied successively to the thigh, 
stomach and thorax, the tone wi h reference to duration and 
intensify is different in all three situations. Over the stomach 
the greatest and over the thigh the least resonance is obtained ; 
while over the lung the resonance is weak. In relaxation of the 
lung and over lung cavities the resonance is loud, whereas over 



EXAMINATION OF THE THORAX. 31 

consolidations it is weak. Plegaphony is introduced as a sub- 
stitute for bronchophony when the Utter can not be practiced 
from any cause which prevents the vibration of the vocal cords 
as in diseases of the larynx. In this method of examination, the 
larynx is percussed, the observer auscultating the ch.st wall at 
the same time. The percussion tone in the larynx is conducted 
by the air in the bronchi to the chest wall. Over inliltrated lung, 
the sound loses but little of its original character. Over an 
exudation in the pleura, the sound is weakened or absent. Over 
cavities the sound is loud and tympanitic. Thermo-palpation is a 
new method of examination described by Benczur and Jonas. The 
principle governing it is that the skin, when palpated over air 
containing organs, is warmer than over airless viscera. Thus, 
palpation with the palmar surface of the ringer shows a dimin- 
ished temperature over the regions occupied by the liver, heart 
and spleen, when compared with adjacent parts. It is also 
recommended in defining pathological processes ; the upper border 
of pleural exudations, and the borders of aneurisms and abdo- 
minal tumors are said to be accurately determined. 



INSPECTION. 

This signifies observation of the chest. We determine 
by inspection : 1. Form of Thorax. 2. Thoracic move- 
ments. 3. Frequency of respiration. The normal chest 
is nearly symmetrical. Not over 20 per cent, of people 
have a perfectly symmetrical chest. The anterior walls 
of a normal chest arch forward to the nipples and then 
slope downward to the lower ribs. Even in health, the 
supra-clavicular regions are slightly concave. 

The most common deviations of a perfect chest are slight 
curvatures of the spinal column. This column has a normal 
curvature at the cervical, dorsal, lumbar and sacral regions. A 
curvature of the column convexly backward is called Kyphosis; a 
curvature forward, Lordosis; a lateral curvature, Scoliosis; and 
a curvature laterally and backward, Kyphoscoliosis. Scoliosis 
frequently results from contraction of one lung or chronic changes 
in the pleura. 

Pathological Changes in Shape.— 1. General 
bilateral bulging (barrel-shaped chest) occurs in Emphy- 
sema. 

2. Unilateral dilatationis observed in pleural exudations, 
pneumothorax and croupous pneumonia. 



32 MANUAL OF CLINICAL DIAGNOSIS. 

3. Circumscript bulging in emphysema, encapsulated 
exudations, tumors and enlargement of viscera. 

4. Paralytic Thorax is characteristic of pulmonary 
tuberculosis. Chest is flat, narrow and long; intercostal 
spaces wide, bony structures prominent, and the scapu- 
lar angles project like wings. 

5. Unilateral retraction occurs after pleural exudations 
and contraction of lung. 

Retraction after pleural exudations is explained as follows: 
The lung compressed by fluid and bound by adhesions does not 
expand to its previous dimensions after absorption of the fluid, 
thus allowing the atmospheric pressure to produce retraction of 
the chest on the affected side. 

6. Circumscribed retraction. After retraction of a 
cavity in lung. Observed in supra-clavicular region, it 
may indicate shrinkage of the lung apex. The supra- 
clavicular regions are normally depressed, and it is only 
when the depression is exaggerated, or more marked on 
one side, that apical disease is suspected. 

7. Chicken Breast (pectus carinatum). The sides of the 
chest are flattened and the sternum has a keel shape. 
Observed in children when unusual force is exerted upon 
lungs. 

8. Rickety Chest. A shallow, longitudinal groove is 
found on either side of the chest, at the junction of the 
ribs and costal cartilages. 

9. Funnel Breast. Depression at lower part of sternum. 
Congenital. 

10. Cobbler's Breast. Like former, although acquired, 
and is due to the pressure of instruments against the 
breast. 

Transverse Constriction of the Chest. A well marked depression 
of the lower portion of chest wall in front, from the xiphoid 
cartilage to the axillary line is due to some impediment to the 
free entrance of air into the lower portion of the lungs. It is 
usually present in bronchitis during infancy. 

Thoracic Movements. — In normal respiration, 
inspiration is an active and expiration a passive act. 
The lungs undergo no active movements during respira- 
tion but passively follow the movements of the thorax 
and diaphragm. 



EXAMINATION OF THE THORAX. 33 

Important Muscles of Inspiration. Intercostal muscles 
and diaphragm. In females, the scaleni muscles are 
normally active as muscles of inspiration. 

Accessory Muscles of Inspiration. Sterno-mastoid , 
scaleni, pectorales, serrati and trapezius. These muscles 
are only employed when the blood is overloaded with 
carbonic acid gas, causing difficulty of breathing 
(dyspnoea). 

Muscles of Expiration. Abdominal muscles, quad- 
ratus lumborum and serratus posticus inf. 

The act of expiration is caused normally by the elasticity of the 
chest unaided by muscles. Inspiration is accomplished by the 
elevation of ribs and sternum, and the rotation outward of the 
former by the external and internal intercostal mns les. This 
constitutes the costal type of respiration. Inspiration is further- 
more ai»ied by contraction of the diaphragm {abdominal type of 
respiration). The type of respiration in males is a combination of 
costal and abdominal {Costo abdominal respiration). In females 
and children it is costal. The thoracic movements are usually 
equal on both sides. Sibson^ demonstrated that the right 
expands more than the left side of thorax which Eichhorst 
attributes to the better developed muscles on the right side, 
increased width of right bronchus and larger size of right lung. 
The connection between sex and type of respiration has been 
variously discussed. It is maintained by some that the dia- 
phragm is the essential muscle of respiration, but that its move- 
ments are impeded in women by the wearing of corsets, this 
necessitating the vicarious action of the intercostal muscles. 
Hutchinson maintains that the costal type is present in girls w T ho 
have never worn corsets, and explains the costal respiration in 
females by supposing that pregnancy would interfere with the 
movements of the diaphragm. Perhaps the greater elasticity of 
the thorax in women and children is the cause of the costal type. 

Pathological Changes in Thoracic Move- 
ments. — Costal Respiration in Males occurs in any 
interference with the movements of the diaphragm (pain, 
mechanical obstruction and paralysis). Abdominal 
Respiration in Females occurs in paralysis of the inspira- 
tory muscles and in thoracic pain. 

The action of the diaphragm can be noted by a prominence of 
the epigastrium occurring during inspiration. 

Asymmetry of Respiration is observed in painful tho- 
racic affections, and in diseases of the thoracic viscera. 
inspiratory Retraction of Chest indicates that air does not 

M. C. D. 3 



34 MANUAL OF CLINICAL DIAGNOSIS. 

enter lung alveoli, which allows the external atmospheric 
pressure to preponderate. 

In the lower lateral portions of thorax, physiological retractions 
are often present, but occurring as they do only during the begin- 
ning of inspiration, they are diagnosed from pathological retrac- 
tions which persist during the entire act. 

Diffuse Unilateral Retraction, in obstruction of the main 
bronchus. Expiratory Bulging of Chest, in emphysema 
and phthisis. It can only occur when positive intra- 
thoracic pressure exists. 

Frequency of Respiration. — In the adult male 
there are 16 to 24 respirations per minute. The normal 
relation between frequency of respiration and pulse, is as 
l:3-£ to 4. It takes four times as long for the blood to go 
through the systemic as through the pulmonic circulation. 

The respirations are more frequent in females, [nfluence of 
age on the number of respirations: at birth, 44; 15th to 2( th 
year, 20; 20th to 25th, 18; 25th to 30th; 16; 30th to 50th, 18 times 
per minute. Influence of position on the number of respirations : 
lying, 13; sitting, 19; standing, 22 time3 per minute. During 
sleep, the number of respirations is diminished. 

The respirations are diminished in frequency in cerebral 
affections, infectious diseases, opium poisoning, and in 
stenosis of the air passages. 

When the seat of obstruction is # in the larynx, at every inspi- 
ration the latter descends, to rise again during expiration; 
whereas, in obstruction below the larynx, the latter is compara- 
tively immovable. 

The respirations are increased in frequency in painful 
affections, e. g. pleuritis, rheumatism of the thoracic 
muscles, peritonitis, accumulation of carbonic acid in the 
blood, and from nervous causes, e. g. hysteria. 

An increase in the frequency of respiration also occurs in fever. 
and is due to the direct action of the heated blood on the center 
of respiration in the medulla. In dyspnceic persons, the diffi- 
culty in counting the respirations may be overcome by placing 
the finger on the scaleni muscles (situated in the neck, between 
the trapezius and sterno-mastoid muscles), which at every inspi- 
ration are raised by their contraction. By counting the eleva- 
tions of the finger, the number of respirations is determined. 

The respirations are irregular in coma and Cheyne- 
Stokes* respiration. 



EXAMINATION OF THE THORAX. 85 

Cheyne-Stokes' respiration is a form of dyspnoea in which 
periods of complete cessation from breathing (apncca) are varied 
with periods of slowly rising respiratory movements, which, after 
becoming gradually deeper, become slower and shallower, until 
they cease altogether. Observed in diseases of the brain and heart, 
coma and opium poisoning, although it may occur in health 
during sleep. 

Dyspnoea (difficulty of breathing), occurs when blood 
is surcharged with carbonic acid gas. The forms of 
dyspnoea are inspiratory, expiratory, or a combination 
of both. Inspiratory dyspnoea occurs in paralysis of the 
crico-arytenoidei postici, which in health open glottis ; 
and in narrowing of the air passages. Expiratory 
dyspnoea is observed in bronchial asthma and emphy- 
sema, and when movable tumors so situated below the 
glottis only occlude latter during expiration. 

Respiration is regulated by the nervous system and by stimu- 
lation of the respiratory center in the medulla. As long as the 
oxygen is maintained at a certain standard in the blood, this 
center is not stimulated, but whenever the oxygen is reduced, 
stimulation of the center, characterized by an increase in the 
number of respirations, results. 



PALPATION. 

This is an adjunct to inspection, and is the act of 
laying on the hand. The objects determined are ; pain, 
movements of thorax, palpation of vocal, bronchial, and 
friction fremitus and fluctuation. 

Pain on Pressure is observed in visceral affections involving the 
pleura, and in painful affections of chest- wall. In the diagnosis 
of respiratory diseases, the important fact must be remembered, 
that the development of pain nearly always indicates inflamma- 
tory involvement of the pleura. In intercostal neuralgia, three 
painful points (points douloureux) are usually detected (vertebral, 
lateral, and sternal points). In rheumatism of the thoracic muscles, 
the pain is diffused, and the affected muscles are painful when 
compressed by the fingers. In practicing palpation of the thoracic 
movements, place the hands on symmetrical parts of the thorax. 
In pneumonia, pleuritis, and unilateral tuberculosis, the thorax 
over affected parts is retarded in action. The action of the 
diaphragm is determined by placing both fingers in the epigastric 
region on either side of the median line. An absence of diaphrag- 
matic contraction on one side is present in diaphragmatic 
pleuritis, local peritonitis^ and paralysis of phrenic nerve. 



36 MANUAL OF CLINICAL DIAGNOSIS. 

Vocal Fremitus is the vibration of the thoracic 
walls during speaking, perceptible to the hand. It is 
due to the vibration of the vocal cords in speaking 
communicated by the column of air in trachea and 
bronchi to the air vesicles, and so to the chest- wall. It 
is more evident on the right side of thorax, because the 
right bronchus is more capacious and given off at a 
less acute angle than the left. Vocal fremitus is dimin- 
ished as the distance from larynx: increases. 

The louder and deeper the voice, the more evident the vocal 
fremitus. For this reason it is more evident in males than 
females, while in children it is with difficulty felt. In determi- 
ning vocal fremitus, the palmar surface of hand is applied to 
chest. If greater accuracy is required in limiting the fremitus, 
use linear palpation, which consists in placing one end of 
a rod of wood (a lead pencil will suffice) on the chest, and sup- 
porting the other end with the fingers. In this way the vibra- 
tions of chest- wall are well conducted from a limited area. In 
limiting the situation of solid viscera (liver, spleen, heart,) from 
the lung, linear palpation is well adapted, the fremitus being 
absent over the airless organs. Vocal fremitus is increased in 
consolidation of the lung (better conduction), over cavities with 
den&e walls communicating with a bronchus, and in emaciated 
persons. Vocal fremitus is diminished, or absent, in pleural exuda- 
tions, pneumothorax, obstruction to bronchus, and in excessive 
development of chest coverings (fat and muscles). The student 
will do well to repeat the following experiments : Remove from 
the cadaver, the lungs and trachea. Into latter tie a rubber tube, 
into the end of which introduce a funnel. When the latter is 
spoken into, the hand can readily feel the fremitus over the 1 urn.:. 
Next, inflate a stomach, and placing it over the lung, feel for the 
fremitus, it is absent (analogous condition in pneumothorax). 
Now fill a rubber balloon, or similar object, with water, and 
placing it over the lung, feel for fremitus, it is also absent (analo- 
gous condition in pleural exudations). 

Bronchial Fremitus is sometimes present in bron- 
chitis. In this affection the air in the tubes is thrown 
into extra vibration, by the vibration of the bronchial 
walls and of the fluid contained within them. 

Friction Fremitus {pleural fremitus) is the grating 
of one roughened surface of the pleura over the other. 

Each lung is covered by a serous membrane (visceral layer of 
pleura), which is reflected upon the inner surface of the thorax 
(parietal layer). Both layers are brought in constant contact by 
the movements of respiration, but during health they are smooth, 



EXAMINATION OF THE THORAX. 37 

and no friction results. In inflammation the fibrinous exudation 
conduces to friction fremitus. Fluctuation is present in excessive 
pleural effusion. Palpation may determine the extra or intra- 
pleural origin of pus accumulation. i If the abscess is intra-pleural, 
gradual pressure will cause its disappearance ; not so, if the 
abscess is of extra-pleural origin. 



MENSURATION. 

The circumference of the chest at the height of the 
nipple in healthy men is about 32| inches after deep 
expiration and 36 inches after deep inspiration. The 
average difference after full inspiration and forced expi- 
ration is from 2% to 3^ inches. The Sterno-vertebral 
diameter measures in healthy men, 6^ inches above and 
7 i inches below. The broad diameter in men at the 
height of nipple is 10 inches. The right side of chest 
exceeds the left by about f of an inch in circumference in 
right-handed persons. The relative length of inspiration 
and expiration maybe represented as follows : Inspiration, 
5 ; expiration, 4 ; rest, 1. 

In emphysema expiration is three times as long as inspiration. 
In taking the above measurements a graduated tape is all that is 
necessary. Select the spinous process of a vertebra behind and 
the median line in front as fixed points of measurement. The 
stemo- vertebral and transverse diameters are determined by 
means of callipers. 

Stethometry is a method of graphically recording the 
movements of the chest by means of the stethometer. 

Pneumatometry is a method of measuring the force of 
inspiration and expiration by means of a mercurial 
manometer (Pneumatometer). It shows that the power 
exerted in expiration is greater than in inspiration. The 
inspiratory power is diminished in phthisis, stenosis of 
the air passages and pneumonia. The expiratory power 
is diminished in emphysema, asthma and bronchitis. 

Spirometry is a method of measuring the amount of air 
received into the lungs by means of the spirometer. 

The total capacity of the lungs in men is about 200 to 2,~0 cubic 
inches, in women 163 cubic inches. This capacity inci eases with 
the growth of the body. Tidal air is that which goes in and out in 
ordinary respiration, and is about 33 cubic inches. Reserve air is 



38 MANUAL OF CLINICAL DIAGNOSIS. 

the air which after quiet expiration can be expelled by forced 
expiration, and is about 100 cubic inches. Comple mental an is 
the air which after qnie: inspiration can be introduced by forced 
inspiration, and is about 100 cubic inches. Residual air is the 
air which remains in the lungs after the deepest expiration, and 
is equal to about 100 to 125 cubic inches. 



PERCUSSION. 

This method of diagnosis consists in striking the chest 
walls to elicit sound. It was first used by Auenbrugger 
(born 1722, died 1809), a Viennese physician, in 1761. 
Percussion may be immediate or mediate. Immediate 
Percussion is striking chest wall directly, and is only 
practiced over clavicle or sternum. Mediate Percussion 
is striking the chest wall indirectly by interposing 
media. The medium to receive blow is called pleximeter, 
and may be of ivory, glass, wood, leather, metal or the 
finger. For percussing a hammer (plessor) or finger is 
used. Methods: 1. Finger — Finger Percussion. 2. Fin- 
g er — Pleximeter Percussion. 3. Hammer — Pleximeter Per- 
cussion. 

It is better to rely upon the fingers in percussion. Instru- 
mental is easier than finger percussion, although less reliable. 
The index or second finger of the left hand is applied closely and 
evenly to the chest, and then tapped with the second finger of 
ri^ht hand. A single, double, or repeated percussion blows may 
then be made. In finger— finger percussion we can appreciate 
the resistance of tissues percussed [palpable percussion) and 
adapt the finger to irregularities of the chest. 

Observe the following: 1. Press finger firmlv against part to 
be percussed. 2. Movement of percussing hand must spring 
only from wrist, while forearm is motionless. 3. Blow must be 
sharp and quick, direct and perpendicular. 4. The finger must 
be instantly removed after percussion, so as not to interfere with 
chest vibration. The results obtained by percussion are as much 
due to the method of execution as to the condition of the tissues. 
The force of the percussion blow r is alw T ays secondary to theknm k 
of obtaining full vibration in resonant tissues. The student to 
gain flexibility of the wrist joint should practice movements of 
this joint with the arm adducted toward the thorax and the fore- 
arm at right angles and motionless. Hammer — Pleximeter percus- 
sion is used for class demonstration, to elicit sounds from thickly 
padded parts and for uniformity of stroke. 



PERCUSSION. 39 

Symmetrical Percussion is used for comparison between 
the two sides of the chest. Percuss at symmetrical points, 
using the same percussion blow. This is useful in 
determining slight variations in the percussion sonnd. 

Palpable Percussion determines the resistance of parts 
percussed as perceived by the finger. 

Auscultatory Percussion consists in auscultating the 
chest with the stethoscope while percussion is practiced. 

Linear Percussion consists in limiting the percussion 
blow, e. #., striking on the edge of a coin. 

Respiratory Percussion consists in percussing after deep 
inspiration or prolonged expiration. 

In Emphysema the vesiculotympanitic note is unchanged by 
percussion during the act of breathing. In cases of fluid in the 
pleural cavity, a deep inspiration will clearly define the border 
line between the resonance above and the flat note below. Tn 
bronchitis, the clearness of normal resonance may become impaired ; 
all doubt is at once dissipated by directing the patient to make a 
forced inspiration, when the normal lung resonance is restored. 
Congestion of the lungs in cardiac disease often yields a slight 
dullness on percussion leading to the suspicion of consolidation; 
this will be removed after repeated forced inspirations. 

Topographical Percussion consists in defining the situa- 
tion of viscera by dermography. 

Demography is a method of delineating on the chest with an 
aniline pencil or, better still, with a pencil made for this purpose 
(dermograph) , the limitation of organs obtained by percussion. If 
it is desirable to observe the resurption of exudations, a perma- 
nent line may be made with a stick of nitrate of silver. When 
permanent records are desired for the results obtained by per- 
cussion, schemata of the chest may be used on which may be 
marked with colored inks, the location of viscera, etc. 

Light Percussion is practiced when air-containing tissue is to be 
carefully delineated from airless structures as in topographical 
percussion. Strong Percussion is employed when airless tissue is 
in immediate contact with thorax and overlies air-containing tissue 
and resonance of latter is desired ; or to obtain dullness from air- 
less tissue covered by tissue containing air. The percussion blow 
is propagated from \}£ to 2>£ inches on the surface and to a depth 
of about 2J4 inches. Caution. Every percussion blow is trau- 
matic in action and when often repeated aggravates or may even 
induce inflammatory affections. Over aneurisms (danger of dis- 
lodging thrombus) and painful points, percussion must be light. 
Patients suffering from hxmoptysis should not be percussed. 



10 MANUAL OF CLINICAL DIAGNOSIS. 

The sound produced by percussion of the chest posses- 
ses pitch and intensity. Pitch depends on the number 
of vibrations in a given unit of time. Over anything 
solid (heart, liver) the pitch is high; over normal lung, 
the pitch is low. The greater the quantity of air, the 
lower the pitch. Pitch is highest over fluids because 
they are most dense. Intensity is the loudness of per- 
cussion note and depends chiefly on the force exerted in 
percussion. Percussion sounds may be 1. Clear, 2. Dull, 
3. Tympanitic. Modifications of tympanitic; 1. Amphoric 
or metallic, 2. Cracked-pot or cracked-metal sound. The 
percussion sound is caused by vibration of chest wall and 
the air within the alveoli of lung. 



PERCUSSION OF THE THORAX. 

Over the lung like any other air-containing organ percussion 
yields a clear sound and is called normal vesicular or pulmonary 
resonance. Over the liver and heait like other airless viscera, the 
Bound is dull. The left infra- clavicular region is usually taken 
as the standard of pulmonary resonance. Always percuss sym- 
metrical parts of the thorax, using the same percussion blow. The 
normal percussion note (pulmonary resonance) is compared by 
Flint to the sound elicited by percussing a loaf of bread covered 
wiih a napkin. The posterior thoracic regions do not yield a per- 
cussion note of the same intensity as the anterior regions on 
account of the density of the dorsal muscles. In percussing the 
interscapular space, the patient's head is bowed and the hand on 
either side is made to grasp the convexity of the shoulder. This 
position as suggested by Corson will increase the interscapular 
region more than twofold and will render the dense muscles 
tense and thin, thus reducing to a minimum obstacles to percus- 
sion and auscultation. The percussion note over the apices pos- 
teriorly is less intense in right-handed individuals on the right 
than on the left side (the opposite holds good in left handed indi- 
viduals) owing to the better developed muscles in the former situ- 
ation. Similarly the percussion note is less intense on the right 
side on the anterior surface of the chest. 

Dullness over the lung is obtained : 1. When lung 
adjacent to thorax is deprived of air by infiltration or 
atelectasis. The airless tissue must be flt least l-§ inches 
in extent, in order to be recognized. Infiltration of the 
lung .occurs in pneumonia, phthisis, hemorrhagic 
infarction, tumors and abscess. Atelectasis results from 



PERCUSSION OF THE THORAX. 41 

compression of the lung (pleuritic and pericardial exuda- 
tions) or by an obstruction in the bronchus. 2. When 
fluid (pleuritic effusion) or solid substance (tumor or 
thickened pleura) is between chest and lung. In adults 
400 ccm. of fluid at least, must be present in order to 
be recognized. 

Pleuritic Exudations first accumulate in pleural cavity provided 
no adhesions exist, in the posterior or inferior parts, thence extend- 
ing, if the fluid increases, forward and upward. If the exudation 
was formed during the time patient was in bed, then the upper 
border of dullness will describe a line higher behind than in front. 
If exudation was formed during the time patient was walking 
about then the line is almost horizontal. In exudations under- 
going resorption, the upper border often has a curved course, the 
highest part of which is in the axillary region (Curve of Ellis). 
Inflammatory pleural exudations change little or not at all when 
the patient changes position, because exudation is encapsuled by 
adhesions. This observation has recently been confirmed by the 
investigations of Strauch. Hydrothorax (generally bilateral) gives 
a dullness changeable on position. When air and fluid are pre- 
sent in the pleural cavity (pyo-and sero-pneumothorax), a dullness 
is present in the lower anterior portion of thorax when patient is 
erect, which is supplanted by a tympanitic sound in the recumb- 
ent posture. It will be observed that the finger appreciates an 
increased sense of resistance on percussion when fluid is present 
in the pleural cavity. The presence of large quantities of air or 
fluid in the pleural cavity depresses the diaphragm, enlarges the 
affected half of thorax and dislocates the heart toward the healthy 
side. The depression of the diaphragm in exudation of the right 
pleural sac causes displacement downward of the liver {see percus- 
sion of liver). In exudations on the leftside, the half-moon shaped 
space of Traube disappears. This space is found in normal individ- 
uals between the left lobe of liver, lower border of left luug and 
anterior end of spleen. It extends upwards to the 5th or 6th costal 
cartilage, its upper border describing a convex line directed 
upward. It contains the fundus of the stomach and yields a tym- 
panitic percussion note. Beginning resorption of a pleuritic 
exudation on the left side is first manifested by the reappearance 
of the tympanitic percussion sound of this space. Emphysema 
diminishes and contraction of the left lung increases the extent of 
this space. 

; A Tympanitic sound indicates the presence of air within 
a cavity with elastic walls. The sound over the stomach 
is typically tympanitic. 

Tympanitic sound over the lung is obtained : 1. In 
consolidation of lung which allows transmission of percus- 
sion blow to the air in bronchus and trachea as in con- 



42 MANUAL OF CLINICAL DIAGNOSIS. 

solvation of the upper lobe (William's tracheal tone). 
2. In pathological air conducting cavities, (a) In bron- 
chiectatic or tuberculous cavities, empty of fluid, near 
the surface and at least as large as a walnut, (b) In 
pneumothorax, when the air is under low tension. Usually, 
however the sound is loud but not tympanitic. 

A metallic sound can almost always be obtained in pneumothorax, 
if the following procedure is adopted: fix a plexinieter over the 
affected side and while one observer is percussing the plexirneter 
with a lead pencil, another auscultates the thorax and hears a line 
metallic sound. 

Pyo pneumothorax Subphrenicus is a collection of pus and air 
between th •*. liver and diaphragm on the right side in consequence 
of perforation of the stomach or intestines. Such abscesses more 
rarely occur on the left side. They are diagnosed from pneumo- 
thorax as follows: history of preceding peritonitis, absence of cough 
and expectoration, slight dislocation of the heart only, intercostal 
spaces not bulged, vesicular respiration heard as far down as 
the abscess. Pleuritic friction can be heard throughout the region 
of subphrenic dullness. High punctures in the 5th intercostal 
space show a collection of pus or serum while a low puncture, 
according to Scheurlen, in the 8th intercostal space, yields a pus 
which is always ichorous. 

3. In relaxation of the lung tissue, as in the neigh- 
borhood of exudations and infiltrations. 

4. In incomplete infiltrations when lung tissue con- 
tains air and fluid, as in oedema, catarrhal and croupous 
pneumonia (1st and 3d stages). 

The Amphoric Sound is a concentrated tympanitic 
sound of raised pitch, and denotes a large cavity, with 
firm, elastic walls. It resembles the sound obtained by 
percussing the cheek when the mouth is closed and fully 
but not tensely inflated. It also resembles the sound 
produced on percussing an empty bottle. It is heard 
over cavities of a diameter not less than 2| inches. Also 
heard in pneumothorax when the tension of air is of a 
certain degree. 

Cracked-Pot Sound (bruit de pot felS.) This may be 
imitated by striking the back of the hands loosely folded 
across each other, against the knee ; the sound resulting 
is like the clinking of coin. The conditions necessary 
for its production seem to be the sudden escape of air 
from an inclosed space under pressure. A strong percus- 



PERCUSSION OF THE LUNGS. 43 

sion blow is necessary. It may be heard in healthy 
persons, especially children, if the chest is percussed 
during speaking or crying. Pathological occurrence: 1. 
Over cavities communicating with a bronchus. 2. Over 
pleural effusions. 3. In pneumonia around consolidated 
parts. 4. In pneumothorax with opening in the thoracic 
wall. The cracked-pot sound is clearer when patient 
opens mouth and protrudes tongue during the act of per- 
cussion, or when it is practiced during expiration. 

Wintrich's Change of Note is that in which the percussion note 
is higher when the mouth is open, and lower when it is closed. 
Usually heard in cavities in free communication with a bronchus. 
This phenomenon can be imitated by percussing larnyx with the 
month open and then closed. 

Wintricfi's Interrupted Charge of Tone is the preceding phenom- 
enon ob.-erved on lying down, and absent on sitting up, or vice 
versa. It indicates that the bronchus leading to the cavity is 
obstructed in certain positions by the flaid contents. 

Respiratory Change of Tone is a higher tone in deeper inspira- 
tion, and is heard over cavities. 

Gerhardt's Change of Tone, when present, is an almost certain 
sign of a cavity, and is due to the presence of fluid in a cavity, 
changing the percussion sound according to the position of the 
patient. 

Biermer's Change of Note is the percussion note in seropneu- 
mothorax. It is deeper in the erect than recumbent posture, 
because in the former position the fluid displaces the diaphragm 
downward, thus making the sounding cavity larger. 



PERCUSSION OF THE LUNGS. 

The apices of the lungs extend above the clavicles in the supra- 
clavicular regions from 1-1 % inches; behind they rise in the 
supra- scapular regions to a level with the spinous process of the 
7th cervical vertebra. Resonance of the apices is separated from 
dullness of surrounding structures by light percussion, but care 
must be exercised in percussing away from the trachea. 

Situation of the Lower Border of Right Lung (Figs. 6 and 7). 

In right sternal line; upper border of cartilage of 6th rib. 

" " parasternal " lower " " " " " 

11 " mammary u upper " " " 7th " 

<« " axillary (i lower " 7th rib. 

" " scapular " at 9th rib. 

At vertebral column at 11th dorsal vertebra. 



44 



MANUAL OF CLINICAL DIAGNOSIS. 



Situation of the Lower Border of Left Lung: 

In left mammary line ; upper border of cartilage of 7th rib. 

" " axillary " lower " " " " M 

" " scapular " at 9th rib. 
Along vertebral column at 11th dorsal vertebra. 

In practicing topographical percussion of the lungs, or other 
organs, the percussion blow must be light. In children, the lower 
border of lung is higher by one intercostal space, whereas in the 
old, it is one intercostal space lower. " The lower border of right 
lung is separated from the liver dullness; the lower border of 
left lung from the dullness of the 6pleen and left kidney, and the 
tympanitic sound of the stomach. 



TOPOGRAPHY OF THE LOBES OF THE LUNGS. 

The following table will approximately define the situation of 
the pulmonary lobes on the different surfaces of the thorax. 
(Figs. 6 and 7.) 



Right Lung. 



Upper lobe.. 
Middle M .. 
Lower " ., 



Anterior Surface. 

Extends to 3d or 
4th rib 

From 4th rib down- 
ward 



Lateral Surface. 
Extends to 4th rib. 
4th to 6th rib. 
6th to 8th rib. 



Posterior Surface. 
To spine of scapula. 



From spine of scap- 
ula downward. 



Left Lung. 



Upper lobe 

Lower " «... 



In mammary line 
to 6th rib 



Extends to 4th rib. 

From 4th rib down- 
ward. 



To spine of scapula. 

From spine of scap- 
ula downward. 



Dislocation of Lung Border. — During deep inspi- 
ration the lower border of the lung descends and ascends 
during expiration {active mobility'). During deep inspira- 
tion when the patient is lying on the side, the lung 
may descend as much as 3-| inches. The dislocation 
of the lower lung border is greatest in the axillary 



AUSCULTATION OF THE LUNGS. 45 

line. The dislocation upward during forced expiration 
is slightly less than the dislocation during inspiration. 
During quiet respiration the difference in the pos.tion of 
the lower lung border is not more than y 2 inch. The 
average dislocation of the lower lung border in the 
various lines during forced inspiration is as follows: 
parasternal line, 1 inch; mammary line, \\ inch; axillary 
line, 1^ inch; scapular line, 1 inch. 

Passive mobility. This is observed when the posi- 
tion of patient is changed. In the recumbent, the 
lower lung border descends about -§ inch lower than in 
the erect posture. When lying on the side, passive 
mobility is greatest. Active and passive mobility are 
decreased in emphysema and pleuritis and absent when 
lower lung border is adherent. 

The lower border of the lung is permanently lower in emphysema 
and temporarily during asthmatic attacks. It is higher than 
normal on both sides when diaphragm is pushed upward (air, fluid 
and tumors in abdominal cavity). It is higher on one side in con- 
traction of the lung or pleura. 

The visceral layer of pleura directly covers the lung, whereas 
the parietal layer forms a cavity in which the lung is allowed con- 
siderable movement. This cavity forms spaces in many places 
which are larger than the volume of the luug, especially at its 
lower border. These spaces (complemented or reserve spaces) allow 
of an augmentation of the lung, and it is there where fluid in the 
pleural cavity first accumulates. 



AUSCULTATION. 

Definition. — Application of the ear to the chest for 
the detection of sounds. Methods of auscultation: — 1. 
Mediate or indirect. 2. Immediate or direct. 

Mediate auscultation is practiced with an instrument 
called a stethoscope and is possessed of the following 
advantages : 1. Localization of sound. 2. Obviates 
chest exposure (important in the examination of women) 

3. Avoids contact with the bodies of unhealthy persons. 

4. Intensification of feeble sounds. 5. Exclusion of 
extraneous sounds. 6. Auscultation of regions inacces- 
sible to ear, e. g., supra-clavicular regions. 



46 MANUAL OF CLINICAL DIAGNOSIS. 

Disadvantages of the Stethoscope : 1. By intensification 
sounds are modified. 2. The training of the ear is liable to be 
neglected. 3. The constant use of the stethoscope may impair the 
hearing for feeble sounds. 

Stethoscopes are of various forms and are made of glass, wood, 
gutta-percha, metal and ivory. Binaural stethoscopes are used in 
preference to others, and the objection that they modify and 
exaggerate sounds is of minor consideration when compared to 
their many other advantages. 

Students should accustom themselves to the use of one stetho- 
scope only. Stethoscopes although similarly constructed develop 
certain adventitious sounds, which become gradually excluded by 
the trained ear. It is a common occurrence for students who bor- 
row instruments to auscultate badly. In the selection of a steth- 
oscope, note its proper adaptation to the ears. A soft rubber cup 
attached to the pectoral end of the instrument is of value in aus- 
cultating emaciated patients, the object being to secure perfect 
adaptation of the instrument with the thorax. Immediate or direct 
auscultation of the chest, the latter covered w T ith a towel, is often 
a necessity in rapid examinations; but when it is necessary to 
analyze circumscribed sound the stethoscope is always preferable. 

Gabritchewsky has recently constructed an instrument, the 
pneumatoscope, consisting of two funnels of different sizes, the 
smaller fitting into the larger. The former is provided with a 
vibrating membrane, while the latter is so constructed as to adapt 
itself to the patient's mouth. The apparatus is connected by two 
rubber tubes with the ears of the observer. The patient supports 
the apparatus in front of the mouth and is instructed to breathe 
quietly through the nose. By this means, sounds heard within 
the lungs and produced by percussion are said to be conveyed to 
the ear. 

Auscultation in Health. — Bronchial breathing is 
heard over larynx, trachea and bronchi. Both inspira- 
tory and expiratory sounds resemble the utterance of the 
aspirate H. The expiratory is louder and longer than 
the inspiratory sound. It is also likened to the sound 
produced by blowing down a tube of the same bore as the 
main bronchus. The best situation for hearing it is at 
the 7th cervical vertebra. It is also heard over the upper 
part of the sternum and the inter-scapular region at the 
point of bifurcation of the trachea. 

The results achieved in auscultation are dependent in a measure 
on the way the patient breathes. The patient should be instructed 
how to breathe, before auscultation is attempted, and caut : oned 
to make no noise w T ith the mouth. If this is impossible, let the 
patient breathe through the nose, with closed mouth. 



AUSCULTATION OF THE LUNQS. 47 

Origin of Bronchial Breathing. In the larynx, and ia 
due to the formation of eddies after the air has passed the 
narrow glottis. 

Vesicular Murmur. — This is heard over the chest 
where the lungs are adjacent to the thorax, excepting at 
points where the respiration is bronchial. It is a soft, 
breezy sound, heard usually only during inspiration, and 
is loudest at the end of inspiration. During expiration 
it is an uncertain murmur, and very often absent. By 
saying /, or v, softly, vesicular breathing may be imi- 
tated. Puerile respiration is heard in children, and is 
the vesicular breathing exaggerated. 

Origin of Vesicular Murmur. In the larynx. It is 
bronchial breathing conducted to the ear and modified by 
normal lung. 

The following simple experiment will demonstrate that the 
vesicular murmur is bronchial breathing modified by normal 
lung: If airless tissue, e. g., a piece of liver, is placed over the 
larynx, and the stethoscope is placed over the liver, bronchial 
breathing is heard. If the same experiment is tried with a lung 
which has been inflated, a vesicular murmur is heard. 

Intensity of Vesicular Murmur. This is dependent on 
force of respiration, elasticity of thorax, and density of 
lung tissue. It is heard more distinctly on the right 
than the left side, although Stokes maintains that it is 
louder on the left side. The vesicular murmur is most 
distinct where the lung is thinly covered. It is loud in 
the infra-clavicular, and feeble in the supra-scapular 
region. In i of all normal chests, only inspiration is 
heard in ordinary respiration. 

Bronchial Breathing differs from Vesicular Murmur: 
1. By its higher pitch. 2. By its occurrence in inspira- 
tion and expiration. 3. By its blowing character during 
expiration. 4. By the distinct pause between inspiration 
and expiration. 

The difference between bronchial breathing and vesicular mur- 
mur is with difficulty appreciated by the beginner. In cases of 
doubt it is best to auscultate in those situations where bronchial 
breatking is normally heard, and by comparison the character of 
the sound is easily determined. 



48 MANUAL OF CLINICAL DIAGNOSIS. 

Auscultation in Disease. — 1. Changes in vesicular 
murmur. 2. Bronchial replaces the vesicular murmur. 

3. Undetermined respiratory murmur. 4. Dry rales. 
5. Moist rales. 6. Crepitant rales. 7. Pleural friction 
Bound. 

Changes in Vesicular Murmur: 1. Diminished. 2. 
Increased vesicular murmur. 3. Prolonged expiration. 

4. Jerking respiration. 5. Systolic vesicular respiration. 

Diminished vesicular murmur occurs in obstruction of th8 
bronchi, emphysema, exudations in pleural cavity and whfn 
breathing is painful. Increased vesicular murmur is observed in 
narroning of the bronchi, e. g>, in bronchial catarrh. Prolonged 
expiration is heard when the exit of air from the lung is prevented, 
either from loss of elasticity of the lung (emphysema) or obstruc- 
tion of the bronchi (bronchitis). In health, the expiratory sound 
when heard is not one-third as long as the inspiratory sound. 
Jerking respiration is heard when inspiration instead of being con- 
tinuous is interrupted ; present in bronchitis. Systolic vesicular 
respiration is heard about the cardiac region, when the heart is 
increased in action, the contraction and dilatation of the same 
influencing the entrance of air into the lung. 

Bronchial breathing replaces the vesicular murmur when 
the murmur arising in the larynx is transmitted 
unchanged through consolidated lung to the chest wall, 
e. g n in pneumonia, infarction, tumors, compression of 
lung above pleural exudation, etc. If bronchus leading 
to consolidated area is obstructed (mucus, fibrin, etc ) 
no bronchial breathing is heard, but the same appears 
when the offending object is dislodged by coughing. 
Bronchial breathing is also heard in open pneumothorax 
and over lung cavities as amphoric respiration. 

Forms of bronchial breathing. Amphoric and metamor- 
phosing respiration. 

Amphoric respiration is imitated by blowing into an empty jar. 
It is bronchial breathing possessed of a metallic character. It is 
heard over large lung cavities with dense walls and in pneumo- 
thorax. 

Metamorphosing respiration is characterized by an inspiration 
which begins with a vesicular murmur and then passes over into 
bronchial breathing. It is a certain sign of a cavity and is 
explained by the air reaching the cavity through a narrow bron- 
chus, which, in the second part of inspiration is dilated by the 
air current. 



AUSCULTATION OF THE LUNGS. 49 

Undetermined Respiration represents a form of breath- 
ing bearing the character of neither the vesicular nor 
bronchial. 

Dry Rales are heard in catarrh of the bronchi which 
yield a viscid secretion with swollen mucous membrane. 
Air passing through the narrow tubes produces the sound. 
They are divided into Sibilant and Sonorous Rales. The 
former are whistling or hissing sounds occurring in the 
smaller bronchial tubes. Sonorous rales are snoring or 
cooing sounds produced in the larger air tubes. 

Moist Rales are produced by the breaking of bubbles of 
air in fluid (blood, mucus or pus). They are coarse or 
fine according to their origin in the large or small bron- 
chial tubes. They are modified or disappear on coughing 
owing to dislodgment of mucus. 

They are heard during inspiration and expiration when 
rales are present in abundance, otherwise only during 
inspiration. They are common in bronchitis after secre- 
tion has become established. Also present in cavities 
and when blood and pus are present in the bronchi. 

Metallic or Ringing Rales are heard added to respiratory 
cough or voice sound in a large cavity containing air. 

Bell sound is obtained by percussing the chest with two 
coins, one used as a pleximeter, the other as a plessor 
when a ringing sound is heard. Present in pneumothorax. 

Metallic Tinkling Rales are associated with amphoric 
respiration and are produced by drops of purulent matter 
falling from a large cavity containing air and fluid. Also 
heard in pneumothorax. 

Crepitant Rales occur in the smallest bronchioles and 
air cells and are due to the inspired air forcing open the air 
cells agglutinated by exuded lymph. They resemble the 
noise produced by throwing salt on the fire or rubbing 
the hairs together near the ear, or, better still, by moist- 
ening thumb and index finger and separating them 
rapidly in front of the ear. 

They are, as a rule, only heard during inspiration. They are 
produced in the first {crepitaiio indux) and beginning of tfie 3d 



50 MANUAL OF CLINICAL DIAGNOSIS. 

stage (crepitatio redux) of croupous pneumonia, in catarrhal pneu- 
monia and oedema of the lung. 

Atelectatic Crepitation is heard over collapsed portions 
of lung and disappears after deep inspiration. 

If we remember that the tidal or breathing volume of the air 
amounts to only 33 cubic inches, and the complemental air, which 
is the air taken into the lungs by forced breathing, which, in 
addition to the tidal volume, amounts to about 100 cubic inches, 
and knowing that the average respiratory capacity of an adult is 
about 225 cubic inches, the conclusion is evident, that even in a 
state of health the lungs are imperfectly aerated, and in a con- 
dition of physiological atelectasis. My invariable custom before 
conducting an examination of the lungs is to have the patient 
make repeated forced inspirations. In this way I avoid many 
errors in auscultation and percussion. 

Sub-crepitant Rales are heard during inspiration and 
expiration, and are thus distinguished from crepitant 
rales. They are produced by air currents breaking 
through mucus in small bronchial tubes. Heard in capil- 
lary bronchitis. 

Pleural Friction Sound. The respiratory rubbing of 
the layers of the pleura occurs in health without noise. 
The presence of a fibrinous exudation on their surfaces 
(pleuritis sicca), causes superficial noises {pleuritic fric- 
tion) heard in inspiration and expiration. On palpation, 
pleuritic friction can often be felt. If fluid is present in 
pleural cavity no friction is heard or felt because the 
pleural layers are separated. The absence of friction is 
also noted when adhesion of pleural surfaces is present. 
Friction is heard in all forms of pleuritis, especially in 
the beginning and after disappearance of the serous 
exudation. 

Differential Diagnosis between Rales and Friction Sounds: 1. 
Rales are continuous, friction sounds a series of interrupted jerks. 
2. Cough changes character of rales while friction sound is not 
influenced. 3. Rales are diffused, friction sounds confined to 
a smaller space. 4. Pressure w 7 ith stethoscope in pleuritis is 
painful, and friction sounds are increased, rales are uninflu- 
enced. 5. Friction sounds are superficial and increased by forced 
inspiration. Dr. Bruen directs attention to the value of making 
the chest wall immovable. When the chest is fixed, especially at 
the lower two-thirds, by the hands of an assistant, and the stetho- 
scope or ear is applied over the doubtful sounds, they will be 
found to have disappeared if of pleural origin, but to be fitill pres- 



AUSCULTATION OF THE VOICE. 51 

ent, if rales. Further, cause the patient to incline to the opposite 
6ide to that diseased, and place the hand of the diseased side on 
the head ; this puts the pleura in a state of tension, and will often 
obliterate a friction rale. 



AUSCULTATION OF THE VOICE. 

Vocal Resonance. — During phonation, auscultation 
of the normal chest, except in situations where bronchial 
breathing is heard, distinguishes the voice as a confused 
hum, and words can not be recognized owing to the poor 
conducting quality of the normal lung. 

Bronchophony. — When voice as heard over larynx, 
trachea or bronchi, is conducted to chest, so that spoken 
words become distinct. It has the same significance as 
bronchial respiration. As a pathological condition it 
always denotes consolidation of pulmonary tissue for the 
lung in this state is a better conductor of sound than 
when in a normal condition. 

Pectoriloquy. — This is exaggerated bronchophony. 
It is heard over large and superficial lung cavities, and 
has an amphoric character. 

.ZEgophony. — A variety of bronchophony. A high 
trembling voice and sound likened to the bleating of a 
goat. It is observed when the voice reaches the chest 
wall intermittingly. Present in incomplete compression 
of the bronchi, and at the upper border of a medium-sized 
pleuritic exudation. In speaking with the nose closed 
this sound may be imitated. 

Metallic Sound of the Voice is heard over 
large cavities and in pneumothorax. 

Whispered Voice. — The vibrations producer 1 by 
this voice in the normal condition of the lung tissue are 
too feeble to be appreciated. When solidification of the 
lung or a cavity exists the whispered voice is transmitted 
with unusual distinctness (whispering bronchophony). 

Bacelli observed that in serous exudations of the pleura, the 
whispered voice was conducted to the ear ; whereas, when the 



52 MANUAL OF CLINICAL DIAGNOSIS. 

exudation was purulent, it was not. This sign, called the Pheno- 
menon of Bacelli, was supposed to be of importance in differenti- 
ating serous from purulent exudations; but, not being always 
present in serous, and being occasionally heard in purulent exu- 
dations, it loses much of its practical importance. 



SUCCUSSION. 

This is a splashing sound, produced when air and fluid are 
present in the pleural cavity at the game time (sero- or pyo ■pneumo- 
thorax). The sound is somewhat similar to that obtained by 
shaking a cask containing air and fluid. The direction of Hippo- 
crates, in order to obtain this sound, was to shake the patient by 
grasping the shoulders, and with the ear applied to the chest it 
could be heard. 

The succussion sound is sometimes so loud that it can be heard 
in every part of a room. The less fluid and the greater quantity 
of air, the louder the splashing. Being most pronounced in 
pneumo-hydrothnrax, it may be heard to a lesser degree over very 
large cavities with fluid contents. 

Examination of the Thymus Gland. This ductless gland is a 
temporary organ, attaining its full size about the age of two years. 
It subsequently atrophies, until at puberty it has almost disap- 
peared. It consists of two lateral lobes, and extends from the 
4th costal cartilage to the lower border of the thyroid gland. In 
the mediastinum it rest* upon the pericardium. In children, 
percussion will indicate the presence of this gland by a finger 
breadth dullness in the left sternal line, extending from the 2d to 
the 4th costal cartilage. The thymus gland may be hypertro- 
phied. or the seat of haemorrhage, abscess, tuberculosis, tumors, 
etc. Dullness at the upper part of sternum may also be due to 
aneurism of the arch of aorta, mediastinal tumor, or a subster- 
nal struma. 

Puncture of the Pleura is practiced with an ordinary hypoder- 
mic syringe, with antiseptic precautions. Its object is to deter- 
mine the presence and character of fluid in the pleural cavity. It 
is a harmless procedure, and is further indicated in diagnosing 
pleuritis from other affections (pneumonia, tumors, thickening of 
pleura, etc.) The character of the exudation in pleuritis may be 
serous, sero-fibrinous, sero-purulent, purulent, or haemorrhagic. 

Microscopical Examination of Fluid may reveal the presence of 
streptococci, actinomyces, and bacilli of tuberculosis, although the 
absence of the latter does not exclude tuberculous pleuritis. Car- 
cinomatous cells may be present in carcinomatous pleuritis. 



ASSOCIATION OF PHYSICAL SIGNS. 



63 



ASSOCIATION OF THE PHYSICAL SIGNS 
OF THE LUNGS.— (Altered from Da Costa.) 



Percussion 


Auscultation 

of 
Respiration. 


Auscultation 

OF 

Voice. 


Vocal 

Fremitus. 


Physical Condi- 
tion. 


Clear 


Vesicular mur- 
mur or its 
modifications 


Normal vocal 
resonance 


Unimpaired 


Normal (or nearly) 
lung tissue 


Dull 


Bronchial res- 
piration 


Bronchophony 


Increased 


Consolidation of 
the lung 


DuU 


Absent respira- 
tion. 


Absent voice 


Diminished 
or absent 


Effusion into pleu- 
ral cavity; ob- 
struction of the 
bronchus asso- 
ciated with con- 
solidation of the 
lung. 


Tympanitic 


Cavernous, or 
feeble, ac- 
cording to 
cause. 


Cavernous or 
diminished 


Increased, 
diminished 
or absent 


Cavities of the 
lung ; relaxation 
of the lung tissue; 
pneumothorax. 


Amphoric or 
metallic 


Amphoric or 
metallic. 


Amphoric or 
metallic 


Increased or 
diminished 


Large cavity with 
elastic walls; 
pneumothorax. 


Cracked me- 
tal sound 


Cavernous res- 
piration. 


Cavernous 
voice. 


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PHONOGRAPH IN MED1CIN& 11 



THE PHONOGRAPH IN MEDICINE.* 

A few years have elapsed since Edison devised an instrument 
consisting essentially of a mounted diaphragm, eo fixed as to 
operate a stylus which recorded the inflections of the voice on tin 
foil. With this crude apparatus, which sacrificed distinctness of 
articulation in order to secure a loud tone, not only was sound 
recorded, but reproduced. Attention has of late again been 
directed to an improved phonograph, embodying the same princi- 
ples as the original instiument, but so modified as to be of prac- 
tical value. It is now but a few months since the untiring Edison, 
dissatisfied with his previous achievements, added further 
improvements to the phonograph, making it now automatically 
adjustable and combining the recorder and reproducer in one. 
The perfected phonograph requires no dexterity in manipulation, 
and I will briefly describe the method of taking a phonogram 
with it. 

To record sound, a w r ax cylinder is fitted on to a metal one. 
The diaphragm, which is automatically adjustable, is then made 
to rest on the wax and the instrument is ready for use ; on speak- 
ing into a tube, which is in communication with the diaphragm, 
the sound pulsations are incised by means of a small puint in the 
noiselessly revolving cylinders. Upon examining the wax cylin- 
der, a number of fine lines can be seen, which are an absolute 
equivalent for the sounds made by the voice. All that is neces- 
sary to reproduce the sounds is to move a lever, when another 
self-adjustable point is presented, which passes over the indenta- 
tions in the wax made by the recording needle, and absolute 
reproduction of the voice, even to the lightest shades and varia- 
tions, results. This may be repeated an indefinite number of 
times. The wax cylinders cost twenty-five cents apiece, making 
phonograms for permanent record very expensive. This objection 
will soon be obviated, as mailable cylinders, costing but a few 
cents and available for single records, are to be introduced. 

To run the machine, either an electric motor or foot power may 
be used. I use the latter, as the instrument is under better con- 
trol : An electric motor, however, possesses the advantage of 
rendering the revolutions of the wax cylinder almost noiseless 
an indi^pensible factor in the reproduction of fine sounds. The 
accurate reproduction of the human voice, is well illustrated by 
the following occurrence : A lady on hearing the w T ords of a gen- 
tleman, spoken into my instrument but a few days before, at once 

exclaimed: " I know that voice! It is the voice of Mr. H ." 

I asked her if she knew the gentleman and she replied in the neg- 

♦Reprint from Occidental Medical Times, April, 1890. 



58 MANUAL OF CLINICAL DIAGNOSIS. 

ative, but she had heard him recite once at an entertainment 
many months before. Here is an instance of how unerring is the 
memory for sounds. 

I have employed the phonograph in taking the histories of cases, 
thus saving time and obtaining copious notes. The cylinders can 
be transcribed at the convenience of the amanuensis. This is but 
one of the many practical uses to which it may be put. In physi- 
cal diagnosis the application of the phonograph suggests itself, 
and it is claimed, that in the laboratory of Edison, the normal 
heart sounds were first successfully recorded. Its practical value 
in medicine was tested by the Pans Academy of Sciences and the 
Vienna Medical Society, with results largely in favor of the instru- 
ment. Dr. Bleyer, in an article on " The Phonograph in Physical 
Diagnosis," says that by means of a microphonic stethoscope, he 
was & enabled to record all the thoracic sounds in their varied 
pitch and tone. The sounds thus obtained were projected by 
means of a tin cylinder acting as a resonator and directly instruc- 
ted a large class of students. I must confess, that similar experi- 
ments faithfully executed with all due regard to details, were 
unattended by these results. I found in my investigations, which 
were varied in every possible manner, that the recording of heart 
sounds was practically impossible. The fault rests with the pho- 
nograph. There is no question about the sensitiveness of the 
diaphragm for recording even the feeblest sounds, but the dim- 
culty lies in reproduction. Even loud sounds emanating from the 
chest are with difficulty detected by an ear accustomed to the 
phonograph. When the reproducing needle is adjusted to the 
revolving wax cylinder a hissing sound is heard, the result of fric- 
tion between the needle and the wax. It is this sound which 
interferes with proper reproduction, and I have found that lubri- 
cating the cylinder renders reproduction decidedly more distinct. 
If this objection were obviated, the phonograph would prove an 
ideal instrument in physical diagnosis. 

Many sounds heretofore inappreciable can be brought out by the 
phonograph. The deepest tone that we are able to appreciate con- 
tains 16 vibrations a second ; the phonograph will record 10 vibra- 
tions or less, and can then raise the pitch until we hear a repro- 
duction from them. Similarly, vibrations above the highest rate 
audible to the ear can be recorded and then reproduced by lower- 
' ing the pitch. I have been able to record nearly all the percussion 
sounds of sufficient intensity, and with a degree of distinctness 
which is remarkable. The percussion sounds obtained in this way 
are exaggerated, and the method resembles auscultatory percus- 
sion. The fine lines which can be seen on the wax cylinder after 
talking into the phonograph convey a fair idea of the number and 
variety of air waves necessary to the production of words and sen- 
tences. 

In clinical medicine the uses of the phonograph are varied. 
The different anomalies of speech, whether due to paresis, paraly- 
sis, tremor, spasm, or even ataxia of the muscles of articulation! 



PHONOGRAPH IN MEDICINE. 59 

can be faithfully recorded. Coughs of various kinds can also 
receive accurate registration . 

Determining the sense of hearing is of great importance to the 
aurist, and the present apparatus for this purpose is unsatisfactory. 
Koosa, in his text-book, refers to the characteristic answer of a 
boy who, upon being tested by the ticking of a watch, suddenly 
exclaimed: "What do I care about hearing a watch ? I want to 
hear what people say V Dr. Lichtwitz, in a recent article on "The 
Phonograph in Otology and Laryngology, " considers the follow- 
ing as essential to an apparatus for ascertaining the perception of 
sound ; (1) It should produce all the tones and murmurs appreci- 
ated by a normal ear, and especially speech in all its inflections. 
(2) It should be a constant sound producer. (3) It should be an 
universal apparatus, so that otologists in different countries can 
express themselves definitely regarding the acuteness of hearing, 
as ophthalmologists do in testing vision. (4) Its use should be 
unaccompanied by inconvenience. (5) It should allow of the per- 
ception of sound by bone and air conduction. The phonograph, 
according to this author, absolutely subserves the first two indica- 
tions, and is the best apparatus for determining the sense of hear- 
ing. 

Of all the wonderful accomplishments possessed by the phono- 
graph, its availability for the blind, by placing them in communi- 
cation with the world of literature, far exceeds any similar device 
for the relief of this unfortunate class. By the majority of those 
whose eyesight is impaired or destroyed it will be hailed as a verita- 
ble God-send. Each wax cylinder will receive from 800 to 1,000 
words, and the whole of "Nicholas Niekleby" can be put on four 
cylinders eight inches long with a diameter of five. By a mechan- 
ical process these cylinders can be multiple-copied, which will 
render them comparatively inexpensive. For educational pur- 
poses, as in the study of foreign languages, which to physicians 
is often a necessity, the phonograph is beyond comparison, for no 
system of phonetic spelling or verbal description will convey the 
same pronunciation of a foreign language so well as a machine 
that reproduces the human voice. 

The phonograph is not without a therapeutic use. The psychic 
influence of sound cannot be denied, and we need only recall the 
well-known effects of enlivening music in cheering troops on the 
march or while under the depressing influence of siege, and the 
profound influence of certain music in exciting the highest emo- 
tional centres. When music, and good music at that, can be had 
"on tap," and supplemented by stories, songs and recitations by 
well-known authors, vocalists and elocutionists, the convalescent 
may command a variety of entertainment. 



* CHAPTER V. 

COUGH— SPUTUM. 

Cough is a symptom of disease of the respiratory apparatus. It 
is a reflex act, the result of laryngeal, tracheal, or bronchial irrita- 
tion. The chief object of this act is the expulsion of pathological 
products which, if allowed to accumulate, would result primarily 
in dyspnoea, to be followed by asphyxia. For this reason, the use 
of narcotics which render anaesthetic the respiratory mucous mem- 
brane, are dangerous when the secretions are abundant. The pro- 
bable direct cause of cough is irritation of the fibres of Xhepneumo- 
gastric nerve, or its branches. A cough centre is supposed to exist 
in the floor of the 4th ventricle. Cough may result from irritation 
of the pharynx, esophagus, stomach, liver, spleen, and female geni- 
talia. In many people, cough may be produced by touching the 
nasal mucous membrane with a sound, and many intractable 
spasmodic coughs have been cured by the removal of nasal polypi. 
In about 17 per cent, of persons, cough will follow irritation 
of the external auditory meatus. In hysteria a persistent cough 
may be present. We also speak of a nervous cough. Irritation of 
the alveoli of the lung will not^ result in cough, and secretions 
must first reach the communicating bronchus, before coughing is 
produced. Kinds of cough : 1. Dry cough is present in pleuritis, 
pneumonia (1st stage), acute bronchitis, and broncho-pneumonia. 
2. Moist cough, when the air passages are filled with an abundant 
secretion. 3. Brassy (barking) cough is heard in stenosis of the 
larynx (croup). This cough is usually associated with stridulous 
respiration, when pressure is exerted on the trachea (Aneurisms, 
tumors). 4. Whooping- cough in pertussis. It is along drawn, crow- 
ing sound, coincident with inspiration, and follows a violent series 
of coughs. It is due to the passage of air through the spasmodi- 
cally closed glottis. 

In Laryngismus Stridulus, a crowing inspiration resembling that 
of pertussis, although not usually associated with cough, is heard, 
and is also due to spasm of the glottis. A pharyngeal cough is 
frequently attended with vomiting. An empyema perforating the 
air passages, is followed by sudden and copious expectoration. 
In phthisis, cough is often dependent on the ingestion of food, and 
is caused by epiglottis, the seat of tuberculous infiltration, imper- 
fectly closing the opening of larynx. 
(60) 



SPUTUM- 61 

Signs Obtained by Coughing (Tussive signs). — Auscultatory signs 
obtained by respiration and the voice, may likewise be obtained 
by acts of coughing. Coughing will remove accumulations of 
mucus within bronchial tubes, and thus restore a diminished or 
suppressed murmur over some part of chest. In coughing, more 
air is expelled than by an ordinary expiration, and in the follow- 
ing inspiration the vesicles capable of greater expansion, give rise 
to a proportionately loud inspiiatory 6ound, thus intensifying 
normal and abnormal inspiratory sounds. Cavernous gurgling 
may be obtained very distinctly with cough. Cough changes the 
character of rales, leaving friction sound uninfluenced. 



SPUTUM. 

Origin of the Sputum. — The constituents are furnished by the 
secretions of the pulmonary alveoli, bronchial tubes, larynx, phar- 
ynx, mouth and the nares with their adjacent cavities. In health 
the secretion from the air-passages does not exceed in quantity 
that required to moisten the mucous surfaces. In disease the 
secretion may be in excess and contain many new constituents. 
Children and aged individuals usually swallow the sputum. 
Chemical analysis of the sputum is rarely of diagnostic value. 
In the examination of the sputum we note: 1. Consistency. 
2. Color. 3. Odor. 4. Quantity. 5. Reaction. 

Consistency is dependent on the quantity of mucus. 
In pneumonia the sputum is very viscid while purulent 
SDutum has little consistency. 



sputum has little consistency 



Color. — Whitish or colorless in mucous, yellowish in 
muco-purulent, and greenish in purulent sputum. 

When the blood-coloring matter in the sputum is altered the color 
imparted may be red, brown or yellowish green. Yellow-ochre 
color (presence of hcematoidin) is present in abscess of the lung. 
A green color (biie pigments) is met with in pneumonia compli- 
cated by icterus. A green color may also be caused by micro- 
organisms. The sputum may be colored blue (laborers in dye 
works), black (coal laborers) and ochre-colored and red (iron- work- 
ers.) 

Odor. — Very fetid in dilated bronchi, putrid bron- 
chitis and gangrene of the lung. 

Quantity. — Daily estimation is of value in controlling 
the progress of a case. The quantity is large in purulent 



62 MANUAL OF CLINICAL DIAGNOSIS. 

bronchitis, dilated bronchi, tuberculous cavities, oedema, 
abscess, etc. 

Reaction. — Usually alkaline. 

According to the principal constituents, the sputum may be 
divided as follows : 1. Mucous. It resembles the natural secre- 
tion. It is tough, transparent and colorless, and is present in 
beginning bronchitis. 2. Purulent. It is of a greenish-yellow 
color, and is found in rupture of abscesses from the lung or neigh- 
boring organs, empyema, chronic bronchitis (bronchorrhoea), etc. 
3. Serous. Pathognomonic of lung-cedema. 4. Bloody (haemop- 
tysis). Present in the first stage of tuberculosis (initial haemoptysis) 
or in any part of its course : in cardiac disease when venous stasis 
develops (particularly in mitral lesions) : aneurisms (bleeding pro- 
fuse); haernorrhagic infarctions, etc. 

We also distinguish the following mixed forms : 1. Mucopuru- 
lent in bronchitis (mucus and pus intimately mixed) and phthisis. 
In the latter affection, the mucus and pus are not mixed and the 
pus is in the form of balls covered with mucus which sink in 
water {sputum globosum). 

2. Sanguineo-mucous found in carcinoma of the lung (raspberry- 
jelly sputum), pneumonia (1st. stage), and hemorrhagic infarction. 

3. Sanguineo-serous (prune-juice sputum) is found in oedema of 
the lung and pneumonia. Blood-colored saliva may be expecto- 
rated by hysterical individuals who often prick and suck their 
gums: the blood is more watery than usual and is generally not 
aerated. Shreds of the parenchyma of the lung may be found in 
abscess and gangrene of the lung. 

With the microscope the following constituents may 
be found in the sputum : 

1. White Blood Corpuscles. Always present, and 
especially abundant in purulent sputum. 

2. Red Blood Corpuscles. Present in bloody sputum. 
Corpuscles are preserved in form, although pale. 

3. Epithelium. Pavement (Fig. 8, a) from the buccal 
cavity and true vocal cords. Cylindrical, from the nasal 
cavity, upper part of pharynx, the larynx and bronchi. 
Alveolar (fig. 8, b) from the alveoli of lungs and finest 
bronchi. They are large, round or oval cells, and many 
contain fat, carbon and myeline. They are of no special 
diagnostic importance, but their presence in large quan- 
tities might suggest tuberculosis. 



MICROSCOPY OF SPUTUM, 



6S 



4. Crystals. Charcot- Ley den Crystals (Fig. 8, c). 
Colorless pointed octahedra, insoluble in cold water, 
ether, alcohol or chloroform, but easily soluble in alka- 
lies, mineral acids, warm water and acetic acid. 







Fig. 8. a. Epithelium from mouth, h. Epithelium from 
lung alveoli containing granules of black pigment, c. Oharcot- 
Leyden crystals, d. Elastic fibres, e. Spiral of Curschmann. 
f. Echinococcus (scolex and hooklets). g. Actinomyces, h. 
Needles of margaric acid. 

They may at times be seen with unaided eye in yel- 
lowish masses found in the sputum. They are met with 
in bronchial asthma (diagnostic) during and after the 
paroxysm. Also observed (rarely) in acute bronchitis 
and tuberculosis. 

Hcematoidin Crystals appear as amorphous yellow-brownish 
grains, or in rhombic plates and needle-like crystals. They 
come from extravasated blood which has been retained for some 
time in the air passages. 

Needles of Margaric Acid (Fig. 8, h). Soluble in ether or chloro- 
form. Found in gangrene and putrid bronchitis inclosed in 
minute plugs which emit an intensely foul odor. 



64 MANUAL OF CLINICAL DIAGNOSIS. 

Cholesterin Crystals. Rhombic plates (Test: with diluted sul- 
phuric acid and tincture of iodine, a green then a red color). Found 
in old purulent sputum. Crystals of leucin and tyrosin are often 
seen in conjunction with cholesterin. 

Crystals of Oxalate of Lime (in diabetes) and triple phosphate 
(when sputum has undergone decomposition with formation of 
ammonia) have also been observed. 

5. Spirals of Curschmann (Fig. 8, e). May be recog- 
nized with unaided eye as fine threads in small sago-like 
clumps of mucus. They are spiial-shaped bodies with 
a bright central fibre. Curschmann supposed that they 
were diagnostic of bronchial asthma, but they are also 
found in capillary bronchitis, croupous pneumonia and 
pulmonary tuberculosis. They probably consist of mucin. 

6. Corpora Amylacea. Look like amyloid grains, and are 
without clinical importance. 

7. Entozoa. — Echinococcus hydatids (Fig. 8, f ). May develop 
in the lung or come from the liver; Ascaris lumbricoid.es 
derived by migration from intestinal tract ; Eggs of Bilha/zia 
haematobia. 

8. Bronchial Fibrinous Casts.— They are moulds of the finer 
bronchi, and occur in fibrin us inflammations (croupous pneu- 
monia, fibrinous bronchitis). 

9. Elastic Fibres. — (Fig. 8, d.) Observed in all de- 
structive affections of the lung (tuberculosis, gangrene, 
abscess), and rarely from the mucous membrane of the 
respiratory tract, vocal cords or epiglottis. In certain 
cases of lung gangrene the elastic fibres are absent, 
owing to the formation of a ferment which dis-olves 
them. They are recognized by their transparency, 
sharpness of outline and noose-shaped arrangement. 
They stain with a watery solution of magenta. 

Elastic fibres are also derived from the foo I, hence the neces- 
sity of washing the mouth before the sputa are collected. In 
order to find the elastic fibres, select a part of the sputum (case- 
ous plugs preferred), and mix it on a slide with a drop of a ten 
per cent, solution of caustic potash. When the elastic fibres are 
not abundant, mix all the sputa collected in 24 hours with an 
equal bulk of caustic potash, and boil until the mass is fluid. (If 
boiled too long, elastic fibres lose their characteristic appearance); 
now pour the liquefied sputum into a conical -shaped glass and 
examine sediment for the fibres (Fenwick's method). Elastic 
fibres should only be diagnosed when they show an alveolar 
arrangement, or when at least several adhere together. The 
number and mass of elastic fibres convey some idea of the extent 
and rapidity of the destructive process. 



MICROSCOPY OF SPUTUM. 65 

10. Micro-Organisms, Leptothrix buccalis, sarcinve, tubercle-bacil- 
lus, pneumonia microbes, micro-cocci and bacilli, actinomyces, and 
aspergillu*. Leptothrix threads, when found in the mouth, are 
without diagnostic significance. They are present in the bron- 
chial plugs in putrid bronchitis. They are stained blue by a 
solution of iodine in iodide of potash. When this reaction is not 
practiced, they may be confounded with elastic fibres or fatty acid 
crystals. 

Sarcince pulmonis rarely occur in the sputum, and are without 
clinical importance. 

Tubercle Bacillus (Koch). — Found in the sputa in 
pulmonary and laryngeal tuberculosis. Likewise in tuber- 
culosis of the nasal or pharyngeal mucous membrane 
(rare). The presence in the sputum of the bacilli may 
precede all other physical signs of pulmonary tuberculosis; 
and the diagnosis of the latter affection is only then cer- 
tain when the specific organisms have been demonstrated. 
(See page 56.) A failure to find the bacillus, after one 
examination, does not exclude tuberculosis; on the con- 
trary, many examinations are often necessary. The bacilli 
are few in number in the incipient stages of tuberculosis, 
and their presence in the sputum may be intermittent in 
all stages of the disease, when the bronchus communicat- 
ing with the seat of bacillary destruction has been 
occluded, or when a temporary arrest of the destructive 
process has occurred with retention of the bacilli in the 
tissues. Errors in " technique " must also be taken into 
consideration, and when in doubt about the reliability of 
staining solutions, etc., a specimen known to contain the 
bacilli must be stained at the same time. An Abbe sub- 
stage condenser is a decided aid to the discovery of the 
bacilli in cover-glass preparations ; but when this is 
not obtainable, flood the specimen with as much light 
as possible. The microscope should magnify at least 450 
diameters. 

Methods of Staining for the Tubercle Bacillus. Method of 
Ehrlich. — The following solutions are necessary: Solution (1). 
Aniline water (a filtered saturated solution of aniline oil in water). 
Solution (2). Concentrated alcoholic solution of fuchsin. Solu- 
tion (3). Diluted nitric or hydrochloric acid (1:3 water). Solu- 
tion (4). Concentrated watery solution of methyl blue. 

Selection of sputum and preparation of cover glass. — Pour the 
sputum in a vessel with a black back-ground (a black vulcanite 
dish or porcelain plate painted black will do). With a needle 
previously sterilized by heating in the flame of a lamp, search for 

M. C. D. 5 



66 MANUAL OF CLINICAL DIAGNOSIS. 

minute opaque white points about the size of a pin's head or yel- 
lowish masses; if both are absent select from the purulent por- 
tion. Now place a very small quantity of the selected material 
between two cover glasses, which are rubbed together until a thin 
film of the matter is deposited on each. The separated covered 
glasses, protected from dust, are now allowed to dry. When dry 
pass cover glasses three times quickly through a spirit flame to fix 
the preparation and coagulate the albumen, when they are ready 
for staining. 

Staining. — To solution (1) in a watch glass add enough of solu- 
tion (2) until the fluid becomes turbid (about six drops are neces- 
sary). Now float cover glasses in this solution and allow them to 
remain protected from the dust for 24 hours. If time is an object 
staining may be hastened by first heating the solution, as prepared 
above, in a test tube and then pouring it into a w T atch glass to 
which fa then added the glasses, which remain in the solution for 
about ten minutes. The cover glasses are next dipped for a few 
seconds into solution (3) and then washed in water. In this solu- 
tion the glasses must not remain too long, or the bacilli will be 
decolorized. To prevent this possibility a concentrated solution of 
oxalic acid has been recommended, but I do not find this satis- 
factory. After removal from solution (3), all micro-organisms are 
decolorized except the tubercle-bacillus (and lepra-bacillus). To 
color the remaining portion of the specimen (the tubercle-bacilli 
only being colored), a drop or more of solution (4) is added to the 
cover glass and allowed to remain in contact for about one minute. 
Now w T ashin water thoroughly and dry the cover glass, if it is to be 
examined in cedar oil or Canada balsam. The bacilli of tubercu- 
losis, if present, w r ill be seen as intensely stained red rods on a 
blue back-ground. A watery solution of malachite-gieen may be 
substituted for solution (4), the green contrast stain making' the 
red bacilli very evident. 

For rapid staining with ready nrepared solutions, the follow- 
ing method of Gabbet will give excellent results : 
Solution (1) Fuchsin, 1.0 

Absolute alcohol, 10.0 

Carbolic acid, 5.0 

Distilled water, 100.0 
Solution (2) Methyl blue. 2.0 

Sulphuric acid, 25.0 

Distilled water, 100.0 
The cover-glass preparation is placed in solution (1) for 10 
minutes, then washed in water and immersed for 3 minutes in 
solution (2) ; washed again in water, and examined. The bacilli 
are red, back- ground, blue. 

When the bacilli are suspected to be few in number, the method 
of Biedert may be employed : Mix one tablespoonful of sputum 
with two of water, and add 15 drops of caustic soda; cook until 
entire mass is liquified, when it is put into a conical glass and 
allowed to remain for two days, but no longer. ^ The sediment will 
contain elastic fibres and tubercle-bacilli. Stain sediment for the 
latter in the usual way. 



MICROSCOPY OF SPUTUM. 67 

Pneumo-Coccus. — The diagnostic value of this microbe 
is not definitely established. It is invariably present 
in the sputum of croupous pneumonia, although bodies 
practically indistinguishable from it by the aid of 
the microscope are found in broncho-pneumonia, and 
even in healthy persons. The most common variety 
of the pneumo-cocci consists of small, round bodies, 
arranged in pairs (diplococci) , surrounded by a gelatinous 
capsule ; they may occur singly or in strings. 

The pneumo-cocci are best stained by Friedlander's method. 
The cover-glass preparation is put for a few minutes in a one per 
cent, solution of acetic acid ; the excess of acid is blown off by 
means of a pipette, and the glass then allowed to dry. Now intro- 
duce the glass into a solution of methyl aniline violet (aniline 
water, 100 parts, alcoholic solution methyl-violet, 11 parts, absolute 
alcohol, 10 parts), for a few seconds; w r ash in water; dry and 
mount. By this method the capsule is clearly demonstrated. 

Micrococci and bacilli are found in every sputum, but are 
increased in fetid bronchitis, bronchiectasis, and gangrene of the 
lung. 

Actinomyces (ray fungus). — Found in actinomycosis of 
the lung. In obscure cases simulating empyema or 
localized abscess in the thorax, the pus is characteristic. 
It contains little yellow masses as large as a millet-seed, 
or smaller; which show under the microscope, after being 
gently crushed, a large number of fine, radially arranged 
filaments, which end in thick knobs. 

Staining of the ray fundus is not usually necessary, but when 
employed, picro-carmine is excellent, the actinomyces are stained 
yellow, the remaining parts of the specimen, red. 

Aspergillus (glaucus and niger) — Found in the sputum of phthi- 
sis and other destructive processes of the lung. They have been 
identified with a condition of the lung known as Pneumonomycosis 
aspergillina. They are branched filaments without double contour 
and contain pigmented spores. 

THE SPUTUM IN DISEASES OP THE 

RESPIRATORY APPARATUS. 

Croupous Pneumonia. — In the early stages the sputum is colorless 
and small in quantity. Later, at times even a few hours after the 
initial chill, it becomes rusty and unusually viscid. In the second 
stasre of the disease, the rusty color (due to intimate mixture of blood 
and sputum) is most pronounced. As the pneumonia approaches 
resolution, the sputum is of a citron-yellow color. If oedema of the 
lung complicates the affection, the sputum is increased in quan- 



68 MANUAL OF CLINICAL DIAGNOSIS. 

tity, and is fluid and foamy. In unfavorable cases, sputum looks 
like prune juice. Green color of sputum, when icterus complicates 
the pneumonia or when resolution is protracted, or when abscess 
of the lung follows. Fine fibrinous bronchial casts (detected by 
shaking sputum in water) belong to the stage of hepatization, 
appearing on the third and disappearing on the seventh day of 
disease. Pneumo- cocci. 

Abscess of the Lung. — Expectoration abundant and resembles 
pus. Odor like butter-milk; becomes fetid when gangrene is 
present. Sputum in standing separates into an upper watery and 
lower layer consisting of pus corpuscles. Minute pieces of lung 
tissue may be present. Microscopical examination: Lung tissue 
and elastic fibres with alveolar arrangement. 

Gangrene of the Lung. — Abundant expectoration of a fetid odor 
and dirty green color. Sputum separates on standing into three 
layers. Upper layer frothy and turbid ; middle, watery and lower 
layer viscid and made up of a sediment of pus corpuscles,bronchial 
plugs containing leptothrix pulmonalis, cercomonas, fat drops, 
etc. Elastic fibres usually absent owing to the action of a ferment 
which destroys them. 

Hemorrhagic Infarction. — When recent, compact blood masses 
intimately mixed with mucus and of a light red color are expec- 
torated. After several days sputum becomes brownish. 

Tuberculosis. — In acute miliary tuberculosis no tubercle-bacilli 
are found. Character of sputum in pulmonary tuberculosis varies 
according to the anatomical condition existing and stage of disease. 
The presence of the tubercle-bacillus is alone diagnostic. The num- 
ber of bacilli present is usually no index of the severity of the dis- 
ease. They are more abundantin pyrexial than apyrexial periods. 
When haemoptysis occurs, they are apparently diminished owing 
to dilution of sputum with blood. Elastic fibres also present, but 
show only lung destruction, the character of which is determined 
by demonstrating the tubercle-bacilli. 

Pneumonoconiosis. — A condition of the lung traceable to the con- 
stant inhalation of dust or irritating particles. In anthracosis, 
sputum contains particles of carbon, and the color is gray or black. 
In siderosis pulmonum due to inhalation of iron dust, the^ sputum 
is of a brownish black color. Leucocytes and alveolar epithelium 
as in former condition are filled with pigment. 

Bronchitis. — Character varies according to the form and stage of 
the affection. In the early stages it is mucous {sputum crudum), 
while later it is muco-purulent (sputum coctum). When this affection 
is of long standing, it may be wholly purulent. In fibrinous bron- 
chitis regularly formed casts of the tubes are found. In putrid 
bronchitis odor of sputum is like that of gangrene, but it containg 
no elastic fibres or particles of exfoliated lung. 

Bronchiectasis. — Sputum abundant, especially in the morning. 
Owing to stagnation it is often fetid. 

Bronchial Asthma. — Sputum is muco-purulent and somewhat 
frothy. Asthma crystals. Spirals of Curschmann. 



CHAPTER VI. 

EXAMINATION OP THE HEART. 

Methods: 1. Inspection. 2. Palpation. 3. Percussion. 
4. Auscultation. 

INSPECTION AND PALPATION. 

Inspection of the cardiac region in a healthy person shows no 
difference in comparison with a corresponding region on the right 
Bide. A protrusion of the cardiac region is called voussure, which 
is present in enlargement of the heart and when air or fluid is 
present in the pericardial sac. The degree of protrusion is 
dependent on the size of heart, the quantity of air or fluid and 
the resistance of the thorax. 

The heart's action is discernible in healthy persons either as a 
diffuse vibration of the cardiac region or as a circumscribed eleva- 
tion in the lower portion of the same region. The first is the 
impulse of the heart, the second, the apex beat. The apex beat may 
be brought into prominence for clinical purposes by directing the 
patient to breathe rapidly or to make physical exertion of some 
kind. 

In investigating the apex beat we observe the follow- 
ing: 1. Location. 2. Breadth. 3. Force. 4. Time. 5. 
Rythm. The location of apex beat is in the 5th left inter- 
costal space between the left mammary and parasternal 
line. The normal location of apex beat excludes as a 
rule; hypertrophy, dilatation, pericardial effusion and 
dislocation of the heart. 

Physiological change in the location of apex beat: 1. In 
children up to the 10th year, it may be found in 4th 
intercostal space and more outward. 2. In old age, it may 
be found in 6th intercostal space. 3. During deep inspi- 
ration it may descend one intercostal space. 4. Position: 



70 MANUAL OF CLINICAL DIAGNOSIS. 

Lying on the left side may dislocate apex beat to the left 
axillary line. Lying on the right side will not dislocate it 
more than 1 inch. 5. After physical or mental exertion 
it is diffused. 6. It is higher in short than long chests. 
Causes of apex beat: 1. Change in the form of the heart during 
systole ; its anterior-posterior diameter is increased (Ludwig) and 
apex is dislocated forward, upward, and to the right. 2. Change 
in the position of heart; it descends and turns on its long axis 
(Skoda). 

Pathological change in location : 1. Dislocation of the 
heart. 2. Enlargement of the heart. 

Dislocation of heart occurs in deformities of the thorax, emphy- 
sema, air and fluid in pleural sac and contraction of the lung. It 
is also dislocated upward, when the diaphragm is pressed upon by 
abdominal tumors, ascites, etc. 

Enlargement of heart occurs in hypertrophy and dilatation 
of the left ventricle which dislocate apex beat outward or out- 
ward and downward. Like conditions of the right ventricle 
may dislocate apex slightly toward left side. The student 
will readily appreciate how a dilated right ventricle may dis- 
locate the apex beat and prevent it from reaching the chest sur- 
face by the following experiment : Put one finger on the 
apex beat and another on the pulse of some artery ; now suspend 
respiration, and, as the sense of suffocation approaches, the apex 
grow T s indistinct and may even disappear while the pulse is not 
manifestly affected, showing that the left ventricle is still contract- 
ing efficiently. When fluid and air are present in the pleural sac 
the dislocation of the apex is greater in accumulations on the right 
than on the left side. In dislocation from the causes last men- 
tioned the heart is pushed il in loto" to one side. 

The normal breadth of apex beat may be covered by the 
ungual phalanx of index finger and measures about 1 
inch. 

Increase in breadth occurs when heart is approximated 
to chest wall ; e. g. contraction of lung, deformities of 
thorax and cardiac dilatation. 

The normal force of apex beat is determined by palpa- 
tion in health. Increase in force is observed in increased 
cardiac activity with or without (fever, exercise, etc.,) 
organic change. 

When heart is dislocated toward chest-wall, there is an apparent 
increase in force. Permanent increase in force and breadth is the 
most important sign of hypertrophy of the left ventricle. 

Diminished force of apex beat may exist in health, owing 



INSPECTION AND PALPATION OF HEART. 71 

to narrow intercostal spaces, increase in the coverings of 
the chest-wall, and from other causes not always under- 
stood. 

Diminished force in disease is observed in emphysema, fluid in 
pleura or pericardium (which act by dislocating heart from chest- 
wall), and degeneration of heart-muscle. 

Disappearance of apex beat is an important sign of beginning 
exudation in pericarditis. In this affection, the weakness of the 
apex beat is in marked contrast with the comparatively strong rad- 
ial pulse, and the latter, in exudative pericarditis, is a gpod iudex 
of cardiac activity. Fluid in pericardium will usually dislocate apex 
downwards, for the following reasons: 1. The weight of heart is 
greater than the fluid, the latter occupying the upper, the heart, 
the lower part of pericardial sac. 2. Diaphragm and heart are 
pushed downward owing to the w T eight of the fluid. 

The time of apex beat is usually synchronous with the 
pulse in the carotid and radial arteries. 

The synchronism of apex beat and carotid pulse may be noted 
by placing one finger over the carotid artery, the other over the 
apex beat at the same time. Apex beat corresponds with contrac- 
tion of the heart, i. e. systole. When the heart is irregular in 
action, and murmurs are heard, it is often difficult to say whether 
the murmurs are systolic or diastolic; by remembering that the 
carotid pulse is synchronous with the systole of the heart, the 
time of the murmur may be recognized. The Carotid pulse is not 
in reality coincident with the apex beat, inasmuch as the blood 
requires a certain time (0.093 of a second) to reach the artery. 

Duplication of the apex beat is present when two apex 
beats can be felt corresponding with one carotid pulsa- 
tion. Present in mitral lesions, and it is supposed that 
hemisystole exists, i. e. both ventricles do not contract at 
the same time. 

The cardiograph is an instrument for registering the apex beat. 

Abnormal Pulsations. — When present at the base 
of the heart in the second intercostal space to the right 
or left border of the sternum they originate respectively 
from the aorta or pulmonary artery. They are more often 
felt than seen. Systolic pulsations may indicate aneurism 
of these vessels. 

Patella has recently directed attention to visible pulsations 
occurring over the pulmonary artery in anaemia. 

Pulsations about the heart region occur in empyema of 
the left side (empyema pulsans) and in aortic aneurisms. 



72 



MANUAL OF CLINICAL DIAGNOSIS. 



A diastolic impulse may be felt over the aorta or pulmon- 
ary artery, more frequently over the latter, and is due to 
the closure of the semilunar valves. When the heart and 
lungs are normal, it is not felt. It is usually observed 
when the right ventricle is hypertrophied or when the 
lung covering of heart is diminished or the lung consol- 
idated. 

Systolic retractions in cardiac region, when observed in 
two or more intercostal spaces, may indicate adhesive 
pericarditis with mediastino-pericarditis. 

Thrills in the heart region are sensations felt by the 
hand similar to that perceived upon stroking the back of 
a purring cat. They are also called Jremissement cataire 
or purring tremors. 

Time and significance of thrills : 1, Presystolic ; 2, Sys- 
tolic ; 3, Diastolic. They correspond with murmurs and 
are heard loudest in the same situations. They are nearly 
always indicative of a valvular lesion. 

Pericardial thrill occurs in pericarditis and is caused 
by the rubbing together of the roughened layers of the 
pericardium. 

TABLE OF THRILLS. 



I. At apex beat. 



II At the 2d right intercostal space, 
close to border of sternum. 



III. At the right sternal border at 
5th aad 6th costal cartilage. 



IV. At the 2d left intercostal space, 
close to border of sternum. 



1. Systolic thrill— Mitral insufficiency. 

2. Diastolic or presystolic thrill— Mitral 

stenosis. 



3. Systolic thrill— Aortic stenosis. 

4. Diastolic thrill— Aortic insufficiency. 



5. Systolic thrill — Tricuspid insuffi- 

ciency. 

6. Diastolic or presystolic thrill— Tricus- 

pid stenosis. 



7. Systolic thrill— Pulmonary stenosis. 

8. Diastolic thrill- Pulmonary insuffi- 

ciency. 



Epigastric systolic pulsations are observed in the^ epigastric 
region when the diaphragm is low and the heart, particularly the 
right ventricle is approximated to the abdominal wall, or when 



PERCUSSION OF THE HEART. 73 

hypertrophy of the right ventricle is present. Also present in abdom- 
inal aneurism. Pulsations in this region may also be transmitted 
by the liver, enlarged stomach or tumors overlying aorta. When 
the abdominal walls are thin, aortic pulsations may be observed 
as a normal condition. The knee-elbow position will, as a rule, 
remove a transmitted pulsation, but if aneurism is present it will 
continue to pulsate distinctly. 



PERCUSSION OF THE HEART. 

Over the anterior surface of the heart uncovered by lung, flat- 
ness is obtained on percussion. This is in accordance with the 
general rule that all airless tissues, whatever their histological 
structure may be, give a pronounced dull sound on percussion. 
The anterior surface of the heart at its upper part and right half, 
being covered by lung tissue, yields, when the latter is not too 
dense, a dull sound on percussion. It will be seen from this, that 
two different forms of cardiac dullness are obtained ; and further- 
more, that where the lung tissue covering the heart is too dense, 
simple percussion will yield no results. 

Forms of cardiac dullness : 1. Superficial or absolute. 
2. Deep or relative. 3. Resistance of the heart. 

Superficial or absolute cardiac dullness (Fig. 6), is 
obtained by weak percussion only. It represents that 
portion of the heart uncovered by lung tissue, and is the 
easiest to obtain. 

A small portion of uncovered heart behind the sternum gives 
resonance on percussion, because the percussion blow is conveyed 
by the sternum to the adjacent lung structure. 

The superficial cardiac dullness begins above, at the 
lower border of the 4th rib; the right boundary is at the 
left border of the sternum, the left boundary is formed by 
a line drawn from the 4th costal cartilage, curving con- 
vexly around, and ending at the apex beat. The lower 
boundary can not as a rule be determined by percussion, 
owing to the almost immediate contact of the left lobe of 
the liver with the heart. We may theoretically construct 
the lower border by drawing a line from the apex beat to 
the sternal insertion of the 6th rib on the left side. 

The absolute cardiac duHness in children is relatively greater 
(large heart) than in adults. It may begin above in the 3d inter- 
costal space, with its left border at or near the mammary line and 
the apex beat at the 4th intercostal space. In aged persons 
the area of cardiac dullness is diminished (emphysema.) 



74 MANUAL OF CLINICAL DIAGNOSIS. 

Area of cardiac dullness in respiration. Quiet respiration does 
not appreciably affect dullness. Forced inspiration diminishes, 
and expiration increases the area of dullness. Deep inspiration 
in certain persons may cause an entire disappearance of cardiac 
dullness. 

Deep or relative cardiac dullness does not actually repro- 
duce the entire size of the heart. Strong percussion is 
necessary. Like the absolute, it forms a triangular-shaped 
figure of dullness. The upper border is at the sternal 
insertion of the 3d left costal cartilage; the right boundary 
is at the right border of the sternum; the left boundary is 
formed by a line drawn from the upper border to the 
apex beat, exceeding the left boundary of absolute dull- 
ness by about one inch. 

Resistance of the heart. This method, introduced by 
Ebstein, and determined by palpable percussion, is sup- 
posed to reproduce the actual size of the heart, a view 
which is justly questioned by competent observers. 

Regarding the diagnostic value of the different forms of cardiac 
dullness, no unanimity of opinion exists. While percussion for 
the absolute dullness is generally employed owing to its compari- 
tive simplicity, it is influenced by the position of the lung borders 
which, when consolidated or retracted, would give an apparent 
increase and when emphysematous an apparent decrease in the 
area of dullness. The determination of the relative cardiac dull- 
ness is largely influenced by the prejudiced wish of the observer. 
It does not reproduce the entire size of the heart, because the 
lung tissue covering the latter at certain parts is too dense, thus 
preventing the blow reaching the dullness beneath. It is 
decidedly inferior in accuracy to the former method, which, while 
presenting many errors, their careful elimination is possible by 
other physical signs. 

The area of cardiac dullness is increased in hypertrophy 
and dilatation of the heart. The dullness is increased from 
above, downwards and outwards when the left ventricle 
alone is involved, while in hypertrophy and dilatation of 
the right ventricle the heart's dullness is broader and 
increased toward the right side. When both ventricles 
are implicated the dullness is increased transversely and 
longitudinally. 

Fluid in the pericardial sac (Hydropericardium). The 
characteristic feature of this dullness is, that the outline 
of precordial flatness is a blunt cone. An important sign 
is the change of the area of flatness in different posi- 



PERCUSSION OF THE HEART. 75 

tions. The dullness is first increased upwards on a level 
with the first intercostal space and laterally at the base. 

The dullness is usually extended to the left of the 
apex beat. 

The cardiac dullness may be apparently increased even when 
the heart is normal as in retraction of the lung. In such a case, the 
lung borders about the heart undergo no change of position dur- 
ing respiration. An apparent increase of cardiac dullness may 
also occur in pleuritic effusions on the left side, or when the lung 
adjacent to the heart is infiltrated, or when tumors are present. 
Percussion in such cases is of no value in defining the cardiac 
dullness and recourse must be had to other signs. 

The area of cardiac dullness is diminished in atrophy of 
the heart, emphysema of the lung and mediastinum, and 
pneumo-pericardium. 

In emphysema the increased volume of lung causes it to envelop 
the area of cardiac dullness and replaces it by a vesiculotympan- 
itic resonance. In pneumo pericardium, there is hyper-resonance 
over the prsecordia, sometimes of a distinctly metallic character, 
when the patient is on his back ; when he sits up this disappears. 

Changes in location of the heart. In transposition of the viscera 
(situs viscerum trans versus) the heart dullness and apex beat are 
found in the corresponding place on the opposite side. The heart 
mav be dislocated to the right or left by pleuritic fluid, adhesions, 
abdominal accumulations, tumors, etc. 

WEIGHT OF THE HEART. 

Average male 10—12 oz. (Gray). 

" female 8—10 oz. « 

SIZE. 

Length 5 inches. 

Width Z% " 

Thickness 2>£ " 

THICKNESS OF HEART WALLS. 

Thickness of right auricle 1 line(l-12th of an inch.) 

"left " 1% lines. 

" " right ventricle 2}| to 3 lines. 

11 " left " 4 to 5 lines. 

CAPACITY OF VENTRICLES. 

Capacity of right ventricle 2 fl. oz. 

11 " left " 2fl.oz. 

SIZE OF THE VALVULAR OPENINGS. 

Aortic orifice 1 In. 

Mitral " 1.8 in. 

Pulmonary orifice 1.2 in. 

Tricuspid " 2 in. 



76 



MANUAL OF CLINICAL DIAGNOSIS. 



AUSCULTATION OF THE HEART. 

Indirect Auscultation with the small attachment of the stetho- 
scope is alone indicated. Auscultate patient in a state of phys- 
ical and psychical rest, and in various positions. Auscultate 
during quiet respiration, then during inspiration and finally in 
expiration. It is often necessary to stimulate cardiac activity 
before auscultation is attempted, this may be done by directing 
patient to make various movements. 

Acoustic Phenomena in Auscultation of the Heart. 1. 
Heart sounds. 2. Endocardial murmurs. 3. Exocardial 
murmurs. 

Heart Sounds. — Two sounds are heard over the 
heart, the first corresponding with ventricular contrac- 
tion, the Systolic tone, the second, the Diastolic tone. 

A very small interval of time is appreciable between the two 
sounds, with a distinct pause after the second sound. The first 
sound corresponding with the apex beat and carotid pulse is 
loudest at the apex, whereas the second sound is loudest at the 
base of the heart, and occupies the first portion of the period of 
diastole. 

Difference Between the 1st and %d Sounds. The first 
sound is longer, duller, and less clear than the second 
sound which is short, sharp and of high pitch. 

The heart tones and murmurs are best heard at their points of 
origin. Auscultation can not always be practiced over the 
anatomical situations of the orifices of the heart owing to certain 
anatomical reasons. The mitral valve can not be auscultated at its 
anatomical situation owing to a covering of dense lung tissue, and 
the aorta is partially covered at its origin by the pulmonary 
artery. The following table gives the anatomical situations of 
the valves and points of auscultation. (See Fig. 6.) 



NAME OP VALVE. 


ANATOMICAL SITUATION. 


POINT OF AUSCULTATION. 


Mitral valve. 


Upper border of the 3d left cos- 
tal cartilage close to the 
sternum. 


Apex beat. 


Tricuspid valve. 


Between the 3d left inter- 
costal space and the 5th 
right costal cartilage. 


Median line on a level 
with the 5th costal 

cartilage. 


Pulmonary valves. 


In the 2d left intercostal space 
close to the left border of 

sternum. 


2d left intercostal space 
close to the left bor- 
der of sternum. 


Aortic valves. 


Between the median line and 
3d left costal cartilage. 


2d right intercostal 
space close to the 
border of sternum. 



AUSCULTATION OF THE HEART. 77 

Number and Origin of Heart Tones. Six sounds are 
heard over the heart. From each venous opening (mitral 
and tricuspid valves), a systolic tone, and from the arte- 
rial openings (aorta and pulmonary), a systolic and dia- 
stolic tone. Two sounds are heard at each opening. 
The second sound at the mitral and tricuspid is trans- 
mitted from the aorta and pulmonary artery. Over the 
ventricles the accent is on the first sound (trochee), over 
the aorta and pulmonary artery it is on the second sound 
(iambus). The second aortic tone is normally stronger 
than the second pulmonary tone. The following schema 
will show on what tone the accentuation falls: 

Mitral valve, I I I I 

Tricuspid valve, \ —-V — V — V 

Pulmonary valves,) | | 

Aortic valves, f V— V— V — 

Duration of the Two Sounds and Two Rests. The entire period of 
the heart action being represented by 10. 

Duration of the first sound, 4 

44 " « rest, I 

14 " 4< second sound, 2 

" " " 4 * rest 3 

—10 
Causes of the heart tones : 
Apex beat (mitral orifice). 

First tone : closure of the mitral valve and contraction of the 
ventricle. 

Second tone : transmitted 2d aortic tone. 

Lower end of sternum on a level with 5th costal cartilage (tri- 
cuspid orifice). 

First Tone: closure of tricuspid valve and contraction of the 
ventricle. 

Second tone: transmitted 2d pulmonary tone. 
Second right (aorta) and left {pulmonary artery) intercostal 
space : 

First tone : sudden tension of the aorta and pulmonary artery, 
and transmitted ventricle tone. 
Second tone: closure of the aortic and pulmonary valves. 

Observe the Following in Auscultation of the Heart Tones: 
1. Rythm. 2. Strength. 3. Reduplication of the heart 
sounds. 

Rythm. The rythm of the heart tones may be changed, 
and still be consistent with a normal heart, these changes 
being due to psychical causes, use of tobacco, sexual 



7S MANUAL OF CLINICAL DIAGNOSIS. 

excesses, or they may be congenital. Variations of rythm 
may, however, be due to degeneration of the myocardium, 
or associated with valvular disease. 

Strength of the Heart Tones. Normally the intensity of 
the tones is influenced by the approximation of the heart 
to the chest-wall, and the density of the latter's coverings. 

In children and emaciated persons, the tones are relatively loud. 
When the heart is pushed toward chest-wall, the tones are also 
loud. They are louder in the erect than in the recumbent 
position. During inspiration, the intensity of the tones is dimin- 
ished, owing to lung covering heart, which is a poor conductor of 
sound ; the contrary holds good when the lung is consolidated. The 
greater the activity of the heart's action, the louder the tones. 

Strengthening of the First Heart Tone is observed when 
the work of the heart is increased, as in hypertrophy; also 
in mitral stenosis. 

The cause of the strengthened first sound in mitral stenosis may 
be explained as follows: In consequence of stenosis, the left ventri- 
cle receives only slowly a small amount of blood ; if, now, a normal 
systole of the ventricle occurs, a decided difference in the tension 
of the valve exists in systole and diastole, resulting in intensifi- 
cation of the systolic tone. 

Strengthening of the 2d Aortic and Pulmonary Tones, 
if lasting, is a most important sign of hypertrophy of the 
left and right ventricles respectively. 

Weakened First Sound occurs in degeneration of the 
heart musculature, emphysema and aortic insufficiency. 

The Systolic tone at the apex is often weakened in aortic insuffi- 
ciency and is owing to the great tension of the mitral valve at the 
end of diastole owing to the regurgitation of blood from the aorta, 
so that at the systole of the ventricle, the tension of this valve not 
being greatly increased the first tone is consequently weak. 

Weakened Second Sound over the Aorta and Pulmonary 
Artery occurs in stenosis of these openings, and is due 
to the diminished blood pressure and vibration of the 
diseased valves. Also present in stenosis or insufficiency 
of the mitral orifice, and is due to the diminished tension 
of the semilunar valves caused by the small quantity of 
blood thrown into the aorta. 

Reduplication of the Heart Tones is observed in 
unequal tension of the blood in both ventricles, which 
causes the valves on both sides to close at different 
times. 



AUSCULTATION OF THE HEART. 79 

Beduplication of the tones may be physiological and dependent 
upon respiration. It may also be associated with pronounced 
disease of the circulatory apparatus. 

Metallic Sounding Heart Tones are heard at times when lung 
cavities are in proximity to the heart ; also in pneumo- thorax, 
pneumopericardium, dilatation of the stomach, etc. 



ENDOCARDIAL MURMURS. 

These murmurs have their origin within the heart, and are 
usually divided into organic and inorganic murmurs. Organic 
murmurs are usually produced by constriction of an orifice of the 
heart (stenosis) or an incomplete closure of the valves {insufficiency). 
The former is called an obstructive, the latter a regurgitant 
murmur. 

Causes of Cardiac Murmurs. — When fluid passes through a tube 
which is suddenly narrowed, eddies are formed, which lead to 
audible murmurs. The more rapid the current the greater are 
the eddies and the louder the murmurs. As the cardiac orifices 
normally represent no decided narrowing, the blood produces no 
murmurs. If an obstruction (stenosis) to the outward flow of 
blood is present, then eddies are formed and murmurs heard. 
Murmurs due to obstructions are heard during systole. Murmurs 
arise in insufficiency of the valves in the following manner: 
After the blood has passed through an orifice, the valves close, but 
being insufficient, a portion regurgitates through the insufficient 
valves, causing a murmur. 

The murmur of insufficiency is heard at the arterial opening 
during diastole, and during systole at the venous openings. 
Roughness of the arterial coats or of the orifices of the heart alone 
will not produce murmurs. 

Cardiac murmurs are differentiated according to time, 
character, and position. 

Time: Murmurs may occur during systole or diastole. 
A murmur peculiar to mitral stenosis and called a pre- 
systolic murmur is heard during the termination of dias- 
tole, or, occurring at the beginning of diastole, it is louder 
during the end. 

Character: This has been variously described as blow- 
ing, rasping, sawing, etc. Murmurs of a musical char- 
acter are sometimes heard and owe their origin as a rule 
to the vibration of a membranous substance, suspended 
in the blood stream. 

Position: This refers to the point where murmurs are 
heard loudest. As a rule murmurs are most intense at 



80 MANUAL OF CLINICAL DIAGNOSIS. 

their point of origin. Murmurs are propagated in the 
direction of the blood current by which they are developed. 

Axioms: — 1. The character or intensity of a murmur is no index 
to the gravity of the lesion producing it. The loudest murmur 
may be produced by the smallest lesion and vice versa. 

2. The intensity of a murmur is largely dependent on the activ- 
ity of the heart. Faint murmurs may often be converted into 
loud murmurs after increasing cardiac activity by active exercise. 
Weakness of the heart may abolish a murmur previously distinct, 
the murmur reappearing after cardio-tonic medication. 

3. A murmur is generally louder when the patient is lying down, 
then when he is standing. Always auscultate murmurs with the 
patient in various positions. 

4. Murmurs are less loud in inspiration than expiration. 

5. Strong pressure on the chest may cause the disappearance of 
murmurs, the pressure inhibiting cardiac action. 

6. When the heart is rapid or irregular in action, it is difficult 
to determine the time of a murmur. Remember that systolic 
murmurs are synchronous with the carotid pulse. Also regulate 
the action of the heart with digitalis. 

7. Systolic are usually louder though less prolonged then dias- 
tolic murmurs. 

8. When murmurs are faint, the patient should suspend respi- 
ration during auscultation. 

Coexistence of Several Murmurs. — This is frequent when insuf- 
ficiency of the valves is combined with stenosis of the same orifice. 
In such a case murmurs would be heard during systole and dias- 
tole. When different orifices are involved at the same time it is 
difficult and even impossible to localize the lesions by ausculta- 
tion alone. 

Endocardial Inorganic Murmurs (anaemic or hsemic 
murmurs). The cause of these murmurs is yet sub judice. 
They have been attributed to disturbances in innerva- 
tion, to relative insufficiency of the valves, i. e. the valves, 
without having undergone any anatomical change, are no 
longer able to close the enlarged orifices of the heart, 
and finally to diminution in the quantity of blood. In 
the latter condition the smaller arteries, veins and capil- 
laries must accommodate themselves to the diminished 
quantity of blood, and contract; but the aorta and pulmo- 
nary artery cannot contract to the same degree; their 
diameter, in consequence, being proportionately larger 
than that of the orifices through which the blood enters 
them, murmurs are produced. 



CARDIAC MURMURS. 



81 



TABULAR VIEW OF CARDIAC VALVULAR 
MURMURS. 



TIME 

OF 

MURMUR. 


USUAL SEAT 

OF 

MURMUR. 


OCCASIONAL SEAT 

OF 

MURMUR. 


CAUSE 

OF 
MURMUR. 


Aortic orifice 
— Systolic 
murmur. 


2d right intercos- 
tal space close 
to the border of 
sternum. 


Over the carotid arte- 
ries. The most wide- 
ly diffused of all car- 
diac murmurs. 


Obstruction to out- 
ward flow of blood 
through aortic ori- 
fice. 


Mitral orifice 

— Systolic 
murmur. 


Apex beat. 


2d left intercostal 
space close to the 
border of sternum; 
may also be tra'smit- 
ted by chest-wall to 
the axillary border 
or beyond it. 


Regurgitation of blood 
through mitral ori- 
fice into left auricle. 


Pulmonary 

orifice — 
Systolic mur- 
mur. 


2d left intercostal 
space close to the 
border of the ster- 
num. 




Obstruction to out- 
ward flow of blood 
through pulmonary 
orifice. 


Tricuspid ori- 
fice—Systo- 
lic murmur. 


Median line of 
sternum on a lev- 
el with 5th costal 
cartilage. 




Regurgitation of blood 
through tricuspid 
orifice into right 
auricle. 


Aortic orifice 
—Diastolic 
murmur. 


2d right intercos- 
tal space close to 
the border of the 
sternum. 


In the middle of ster- 
num. It may also be 
heard over the aorta 
and carotids. 


Regurgitation of blood 
through aortic ori- 
fice into left ventri- 
cle. 


Mitral orifice, 
— Diastolic 
murmur. 


Apex beat. 


Murmur rarely dif- 
fused. Usually lim- 
ited to apex beat. 


Obstruction to the flow 
of blood from left 
auricle to the left 
ventricle. 


Pulmonnry 
orifice —Dias- 
tolic murmur. 


2d left intercostal 
space close to the 
borderof the ster- 
num. 


Down right side of 
heart. 


Regurgitation of blood 
through pulmonary 
orifice into right 
ventricle. 


Tricuspid ori- 
fice— Diastolic 
murmur. 


Median line of 
sternum on a lev- 
el with 5th costal 
cartilage. 


May be transmitted to 
the base of the heart 
or to the right axilla. 


Obstruction to the flow 
of blood from right 
auricle into right 
ventricle. 



Characteristics of anaemic murmurs : — 

1. Usually soft and blowing in character, and not prolonged. 

2. Occur during systole only, and usually systolic tone is heard. 

3. Generally loudest at base of heart. 

M. CD. e 



82 MANUAL OF CLINICAL DIAGNOSIS. 

4. Accompanied with anaemic symptoms, and murmurs in the 
veins of the neck. 

5. Unaccompanied, as a rule, by changes in size of the heart. 

6. They frequently change their character. 

7. Under appropriate treatment of the general condition, th^y 
disappear. 

Ancemic murmurs are usually loudest over the pulmonary artery, 
a point where organic systolic murmurs are frequently heard. 
The chief means of differentiation between the two, lies in the 
fact that with organic murmurs we find dilatation and hypertrophy 
of the hearty which are usually absent in anaemic murmurs. 

Exocardial or Pericardial murmurs. These murmurs 
are friction sounds produced by the rubbing of one sur- 
face of the pericardium upon the other when roughened 
by a fibrinous exudation. 

Characteristics of pericardial murmurs : — 

1. Unlike endocardial murmurs, which are limited to a certain 
phase of the heart's action, they may be systolic, diastolic, or 
both, or even presystolic. 

2. They are increased in intensity upon pressure with the 
stethoscope, which maneuver facilitates the friction between the 
pericardial layers. 

3. During deep inspiration the lung approximates the layers 
of the pericardium, thus increasing pericardial murmurs during 
this phase of respiration. Endocardial murmurs by the same 
act are diminished in intensity, because the interposed lung 
offers a poor medium of conduction to the chest-wall. 

4. Pericardial murmurs are circumscribed, and, unlike endocar- 
dial murmurs, are not transmitted beyond the area of cardiac 
dullness. 

5. Change of position exerts a greater influence on the character 
of pericardial than endocardial murmurs. Pericardial murmurs 
are rendered especially distinct when the patient is in the sitting 
posture, with the body inclined to the left 6ide. 

6. Pericardial murmurs give the impression of being of superfi- 
cial origin. 

7. Pericardial murmurs frequently change their character, thus 
being unlike endocardial murmurs, the character of which is 
almost constant. 

8. Pericardial murmurs are rough, grating to and fro, or rub- 
bing and scratching sounds. 

Extra-Pericardial Murmurs. — These sounds are with difficulty 
distinguished from pericardial sounds proper. They occur when 
the pleura or peritoneum adjacent to the heart is roughened. 
They differ from pericardial murmurs by being dependent more 
on the movements of respiration than of the heart, and they 
may at times be made to disappear by suspending respiration. 

Palpitation of the Heart. — This common complaint ii often 



DIAGNOSIS OF CARDIAC DISEASES. 83 

mistaken by the patient lor some organic heart affection. Among 
the causes are weakness of the heart muscle (fatty degeneration) ; 
excessive use of stimulants (tea, coffee, tobacco), and psychical 
disturbances. It is also frequent in so-called nervous patients. 
It is manifested in the main by paroxysms of increased frequency 
of the heart action, unattended by any increase in the heart 
dullness. When associated with systolic murmurs the latter aie 
usually of anaemic origin. Palpitation as a functional disturbance 
is not associated with dyspnoea and venous stasis or other symp- 
toms peculiar to organic affections of the heart. 

Puncture of Pericardium. — This may be practiced as an aid to 
diagnosis or in the removal of large effusions. The point of 
election, according to Roberts, is in the 5th intercostal spice 
from 2 to 1%. inches to the left of the median line of the sternum. 
Aside from injuring the heart or puncturing the pleura, the 
selection of this point prevents injury to the internal mammary 
artery which runs from X to j£ an inch from the left border of the 
sternum. 



DIAGNOSIS OP CARDIAC DISEASES. 

Hypertrophy of Left Ventricle.— Symptoms: Increased tension of 
the radial pulse, pulsation of temporal and carotid arteries, vertigo, 
headache, florid face, ringing in the ears, epistaxis and iosomnia! 
Physical signs. Inspection : Bulging of praecordial region, apex 
very forcible and extended downwards and to the left. Per- 
cussion; increased dullness downwards and to the left. Auscul- 
tation ; loud heart tones with accentuation of 2d aortic tone. 

Hypertrophy of Right Ventricle.— Symptoms: Stasis in the 
pulmonic circulation leading to dyspnoea, haemoptysis and bron- 
chitis. Physical signs. Inspection; Apex beat diffused and 
marked in the epigastrium. Percussion; increased cardiac dull- 
ness to the right. Auscultation ; accentuation of 2d pulmonary 
tone. 

Dilatation of the Heart. —Symptoms: Peculiar to a feeble 
circulation, turgid veins, feeble pulse, dyspnoea, oedema and 
effusions in the internal cavities and symptoms indicative of con- 
gestion of the viscera. Physical signs. Inspection: Apex beat 
diffused and very feeble. Percussion; Cardiac dullness increased 
to the right or left according to side of heart involved. Ausculta- 
tion ; Cardiac tones are very feeble and indistinct. 

Pericarditis, 1st or dry stage. — Apex beat tumultuous and irregu- 
lar; friction fremitus felt and friction sound heard. 

2d or stage of effusion. — Apex beat feeble and fluttering; cardiac 
dullness of a triangular form. Heart sounds, feeble or absent over 
the area of dullness, but are heard above the line of effusion dis- 
tinctly and loud. 



84 MANUAL OF CLINICAL DIAGNOSIS. 

Sd or stage of absorption. — Disappearance of dullness, and reap- 
pearance of heart tones and friction sound. If effusion is not 
absorbed, the physical signs of 2d stage continue. 

Aortic Regurgitation. — Symptoms; pulsation of the arteries, 
pulse is forcible, but recedes from the finger (waterhammer, or the 
Corrigan pulse) ; capillary pulse. Sphygmographic tracing charac- 
teristic. (See pulse). 

Physical signs. — Bulging precordial region, apex beat extended 
to the left and downwards, increased cardiac dullness to the left. 
Diastolic murmur over the aorta. Systolic murmur at times at 
apex, and accentuation of 2d pulmonary tone. 

Aortic Stenosis. — Vertigo frequent. Apex beat extended to the 
left and downwards. Cardiac dullness increased to the left. Loud 
systolic murmur over aorta ; also heard over other ostia, although 
feeble; 2d aortic tone absent. 

Mitral Regurgitation. — Pulse irregular. Apex beat dislocated 
downwards and outwards and diffused. Apex beat is feeble, and 
a systolic thrill is felt. Increased dullness peculiar to hypertrophy 
and dilatation of right ventricle. Systolic murmur at apex and 
over pulmonary artery, traceable to axillary region and angle of 
scapula. 

Mitral Stenosis. — Apex beat felt in epigastrium and to the right 
of sternum. Presystolic thrill at apex. Percussion same as mitral 
regurgitation. Prolonged presystolic murmur at apex, and usu- 
ally localized. 

Tricuspid Regurgitation. — Increased cardiac dullness to the 
right, systolic murmur over tricuspid valve, weakened 2d pulmo- 
nary tone, venous pulsation. (See examination of the veins.) 

Tricuspid Stenosis. — This is the rarest of all heart diseases. 
Venous stasis occurs, and the symptoms are the same as tricus- 
pid regurgitation. 

Diseases of the pulmonary valves are usually congenital, and 
characterized by pronounced cyanosis, dilatation of the right side 
of heart, and murmurs, according to character of lesion, best 
heard over pulmonary artery. 



CHAPTER VII. 

EXAMINATION OF THE ARTERIES AND 

VEINS. 

The Arteries. — Methods : Inspection, palpation, percussion, auscul- 
tation. 

Inspection. Pulsation of the larger arteries is not 
usually discerned in healthy persons. Pulsations of the 
arteries of the neck are seen when the heart is very much 
increased in action. In hypertrophy of the left ventricle f 
these pulsations are permanent and pronounced. 

Capillary pulse. In healthy individuals, the capillary blood- 
vessels at the roots of the nails often show systolic redness and 
diastolic paleness. This so-called " capillary pulse " becomes 
exaggerated in diseased conditions, notably in aortic regurgitation. 
The explanation of this phenomenon is as follows : In conse- 
quence of the hypertrophy of the left ventricle of the heart, an 
increased quantity of blood received by regurgitation from the 
aoi ta and left ventricle, is thrown into the relatively empty aortic 
system ; then follows a rapid emptying of this system toward the 
capillaries and the heart. 

Ophthalmological examination often shows pulsation of the retinal 
blood-vessels. At times, pulsations of the liver and spleen can be 
felt. F. Mueller has lately called attention to pulsations of the 
soft palate, which he claims are similar in origin and significance 
to the capillary pulse. Capillary pulsation may be demonstrated 
by making lines with some blunt pointed instrument on the skin 
of the forehead, and the lines are 3een to become alternately pale 
and red. 

Palpation. In many of the arteries, notably the radial 
and temporal, the wails are thickened and rigid, and car- 
tilaginous-like plates are felt. This condition is peculiar 
to arterio sclerosis, and is due to calcification of the middle 
arterial coat. 

Auscultation. This is accomplished by means of a 
stethoscope, avoiding pressure of the artery. 

(85) 



86 MANUAL OF CLINICAL DIAGNOSIS. 

Normal auscultation. Over the carotid and subclavian arteries, 
two tones are heard. The first is the transmitted 1st aortic tone, 
the second, the transmitted 2d aortic tone,. 

Over the abdominal aorta and femoral arteries, one tone (due to 
tension of the artery) is at times heard, although as a rule no sounds 
are normally heard. Murmurs heard over arteries are usually 
pathological. The student will do well to familiarize himself with 
certain errors consequent upon unskilled auscultation of the arte- 
ries. For study, select the brachial artery at the elbow joint ; now 
make moderate pressure with the stethoscope on the artery, which 
will develop a murmur (pressure murmur). If the pressure is 
increased to a certain point, a short, sharp tone is produced 
(pressure tone). Auscultation of the carotid artery is practiced at 
almost any part of its accessible course and of the subclavian artery 
above the clavicle, or below in the fossa of Mohrenheim. 

Arterial Murmurs. In aortic stenosis a murmur repla- 
ces the first tone over the carotids. The second tone 
over the carotids and subclavian is replaced by a mur- 
mur in aortic regurgitation. Murmurs originating at the 
mitral and tricuspid valves can likewise be transmitted 
to the arteries. Murmurs from the aorta are best trans- 
mitted by the right, and murmurs from the pulmonary 
artery by the left carotid. 

Locally Produced Arterial Murmurs occur whenever 
an artery in its course is dilated or narrowed. The most 
important of these murmurs is the aneurysmal murmur } 
which may be systolic, diastolic, or both. 

Differences in Symmetrical Arteries. In health sym- 
metrical arteries show the same pulse qualities, unless 
anatomical anomalies exist. Any mechanical obstruc- 
tion, whether due to emboli, aneurisms or tumors com- 
pressing an artery will make a comparative change in 
the qualities of the pulse. 

Examples : If an aneurism involving the arch of the aorta is 
situated between the innominate and left subclavian artery, then 
the pulse of the right radial and carotid arteries can be f^lt 
sooner than in the same arteries on the left side. Again, 
if the aneurism lies between the left carotid and left subclavian 
arteries, the pulse can be felt earlier in both carotids and in 
the right radial artery than in the left radial and femoral arteries. 

Paradoxical Pulse. This occurs when the radial pulse 
disappears either during inspiration or expiration. It is 
caused by adhesions between the subclavian artery and 
the pulmonary pleura. 



THORACIC ANEURISM. 87 

When the shoulders are pressed backwards and downwards 
with the hands on the gluteal regions, and deep inspiration is 
made, the radial pulse on both sides can be made to disappear. 
This is explained by compression of the subclavian arteries 
by the first rib. When the first rib hau become rigid in conse- 
quence of an ossifying perichondritis, a condition peculiar to 
phthisis, tben notwithstanding deep inspiration, the radial pulse is 
still present. 

Percussion is of limited application, although it is useful in 
defining the situation of an aneurism. 

Subclavian murmurs are heard over the subclavian 
arteries either during inspiration (more often) or expira- 
tion. 

These murmurs are frequently present in phthisical persons, and 
the explanation of their occurrence is similar to that of the para- 
doxical pulse, viz. adhesions between the subclavian artery and 
pulmonary pleura. Fuller found the subclavian murmur present 
12 times in 100 healthy persons. 

Brain murmurs are heard in children from the 3d month to the 
6th year by auscultation of the head. Over the regions of the 
fontanelles the murmurs are loudest. They are physiological 
and are transmitted from the carotids. 

Pathological arterial tones are heard over arteries where tones 
are normally absent. In aortic regurgitation, in consequence of 
sudden tension of the arteries, tones are heard corresponding 
with the pulse in peripheral arteries. 

Thyroid arterial murmurs are present in all enlargements of 
this gland. 



THORACIC ANEURISM.* 

Symptoms. Pain is nearly always present. Pressure on vari- 
ous nerves, on the trachea, oesophagus, etc., will produce char- 
acteristic symptoms. 

Physical Signs. — Inspection. Until the aneurism has attained 
a certain size nothing is observed. Later, bulging is apparent 
upon the surface of the chest involving the upper part of, 
or immediately to the right, of the stornum. If the transverse 
portion of the aorta is involved then pulsation is^ observed in the 
supra sternal fossa. The pulsation of an aneurism corresponds 
with the systole of the heart and is equally distended in all parts. 

* Schnell has recently directed attention to an apparatus called tbe 
Aneurysmatoscopc^ for the diagnosis of aneurisms of the descending aorta. It 
consists of an ordinary soft rubber stomach tube closed at its lower end, and 
containing at its upper end a glass tube. The whole is then filled with a 
colored fluid up to the latter. When the tube is introduced into the oesopha- 
gus, the pulsations of the aneurism are transmitted to the fluid in the tube, 
and can thus be recognized. 



88 MANUAL OF CLINICAL DIAGNOSIS. 

Palpation. Careful palpation will discover an abnormal pulsa- 
tion usually systolic in time, even before the aneurism reaches 
the surface of the chest. A systolic or diastolic thrill may accom- 
pany the pulsation. 

Percussion yields a dullness even in the early stages of the 
aneurism, which may be limited to the manubrium or to the right 
of the sternum. The dullness may be continuous with or distinct 
from the cardiac dullness. 

Auscultation. One or both heart sounds maybe heard; or a 
systolic or diastolic murmur or both. At times no sound or mur- 
mur is heard. 



THE VEINS. 

Inspection and palpation. 1. Increased distension of the 
veins. 2. Abnormal movements of the cervical veins. 3. 
Thrombosis. 

Increased Distension. This is present when the return 
of the venous blood to the heart is rendered difficult in 
consequence of general and local causes. 

General causes : Diseases of the heart and lungs. 

Whenever the power of the right auricle and particularly of the 
right ventricle is reduced, these cavities are incompletely emptied 
and the return of venous blood to the heart by means of the supe- 
rior and inferior venae cavae is prevented. The return of venous 
blood to the heart is facilitated by the aspiration of the thorax and 
this is dependent on the elasticity of the lungs. Any affection 
diminishing lung elasticity conduces to venous stasis and abnor- 
mal distension of the veins. 

Local causes : Thrombosis of or compression of the 
veins. Abnormal movements of the cervical veins may be 
respiratory or pulsatory. 

During inspiration the return of venous blood to the heart is 
facilitated, whereas during expiration a physiological hindrance 
exists. When the veins are filled with a normal quantity of blood, 
no respiratory movement is observed. It is only when abnormal 
distension is present, that this movement is discerned. The veins 
may swell only in expiration, in mediastino-pericardiiis owing to a 
diminished caliber of the veins in inspiration. 

Pulsatory movements are dependent on cardiac activity 
and show the same rythm as the latter. The pulsatory 
movement may be communicated or develop in the vein 
itself. 

The first is communicated to the internal jugular vein by the 
pulsation of the carotid artery especially when the latter pulsates 
violently. 



THE VEINS. 89 

If the pulsation of the vein is communicated, pressure with the 
finger on the vein in the middle of the neck, will cause the pulsa- 
tions to cease in the veins below the finger. If the carotid artery 
is effectually compressed the pulsation in the vein will also disap- 
pear showing that it is communicated from the artery. 

True venous pulsation is observed in the jugular veins 
independent of any impulse communicated by the carotid 
artery, and is caused by regurgitation of blood during 
the systole of the heart into the superior vena cava and 
jugular veins. This pulsation is pathognomonic of tri- 
cuspid insufficiency. 

Unlike the communicated pulsation, pressure with the finger 
on the vein, only increases the pulsation "below the finger. The 
true venous pulse is most pronounced in the right internal jugular 
vein. 

Venom Pulse of the Liver. This is a pulsation of the liver pres- 
ent in tricuspid insufficiency and is caused by regurgitation of 
blood into the inferior vena cava. 

In aortic regurgitation pulsation of the liver has been observed 
and is caused by an abnormal distension of the hepatic arteries. 

Auscultation. — Venous tones occur when blood 
regurgitates with a certain force from the heart into the 
veins, thus bringing the valves of the veins into sudden 
tension and causing a tone. Present in tricuspid insuf- 
ficiency. 

Venous murmurs when present are heard most fre- 
quently over the internal jugular vein of the right side at 
its junction with the subclavian to form the innominate. 
These murmurs are usually continuous (continuous hum or 
bruit de diable), and are well marked in ansemic and 
chlorotic persons. 

Pressure on the vein with the stethoscope must be avoided. 

The venous murmur is not confined to either the systole or dias- 
tole of the heart, but persists through both. It is loudest during 
inspiration and is increased in intensity when the head is turned 
to the other side. 



CHAPTER VIII. 
THE PULSE. 

The pulse is the expansion of an artery produced by 
a wave of blood set in motion by the passage of blood 
into the aorta at the systole of the ventricle. Palpation 
determines: 1. The frequency. 2. Therythm. 3. The 
quality of the pulse. 

Frequency of the Pulse. In the healthy adult there is 
an average of 70 beats in a minute, in children 100-140, 
and in old men, 70-90, or more. 

The frequency of pulse is greater in the female than in the male. 
The daily variation in the frequency of the pulse corresponds with 
a like variation in the body temperature. It is most frequent 
between noon and evening, and is least frequent in the early hours 
of the morning. The influence of position is such that it is most 
frequent standing, and least frequent in the recumbent posture. 
External temperature when high increases, when low diminishes 
the frequency. Increased muscular exertion, acceleration of res- 
piration, and psychical activity also increase the frequency of the 
pulse. 

Pathological Pulse Frequency. A slower movement of 
the pulse (pulsus rarus), and acceleration of the pulse 
(pulsus frequens) are distinguished. 

Pulsus Rarus (bradycardia). Observed in conditions 
leading to an irritation of the vagus, or paralysis of the 
' intra-cardiac ganglia and of the sympathetic. Also, 
in increased cranial pressure (meningitis), icterus (from 
the action of the gall acids on the cardiac ganglia), ste- 
nosis of the aortic and mitral orifices, degeneration of the 
myocardium (fatty heart) ; in colic, and after adminis- 
tration of digitalis. 

Pulsus Frequens (tachycardia). Observed in paralysis 
of the vagus, irritation of the sympathetic and affections 
of the cardiac ganglia ; in excessively increased cerebral 

(90) 



THE PULSE. 91 

pressure (last stage of basilar meningitis), acute diseases 
of the heart (peri and endocarditis), and in valvular 
heart diseases when compensation is disturbed. Exces- 
sive rapidity (over 160) is a sign of heart-weakness 
(collapse.) 

Paroxysmal tachycardia is also a symptom of functional dis- 
eases of the heart. In hysteria and Graves' disease the pulse is 
also increased in frequency. 

Eythm of the Pulse. Irregularity of the pulse (pulsus 
irregularis) when observed in children and adults, nearly 
always indicates disease of the heart or brain. In 
advanced age irregularity of the pulse is of no importance. 

Forms of Pulsus Irregularis: Pulsus alternans, a low pulse-wave 
following a high one; pulsus bigeminus, sl long pause after two 
beats; pulsus trigeminus, a long pause after three beats; pulsus 
paradoxus, the pulse is smaller with each inspiration, or disap- 
pears (observed in stenosis of the air-passages, mediastinitis, and 
pericardial adhesions). Retardation, or unequal size of the pulse 
between symmetrical arteries, or between arteries of the upper 
and lower half of the body, is observed in stenosis of the arteries 
and aneurism. 

Quality of the Pulse. In determining the quality, we 
consider: 1. Expansion; 2. Force and tension; 3. 
Size of pulse. 

The arteries distend rapidly (pulsus celer) in hypertrophy of the 
left ventricle and in increased heart action. Pulsus celer is char- 
acteristic of aortic insufficiency, contracted kidney, and exophthalmic 
goitre. The arteries distend slowly (pulsus tardus) in old age 
(senile pulse), aortic and mitral stenosis, and in aneurisms. In 
considering the force and tension of the pulse, we speak of a hard 
(pulsus durus) and a soft (pulsus mollis) pulse. The hardness of the 
pulse is dependent on the tension of the arterial wall ; the greater 
the tension the harder the pulse. Such a pulse is difficult of 
compression. A hard pulse is observed in hypertrophy of the left 
ventricle, and in spasm of the arterial wall, as occurs in lead colic. 
A soft pulse is easily compressed, and is found in cardiac degene- 
ration, fever, and anaemia. In atheroma of the arteries, where 
the walls are infiltrated with calcareous salts, the pulse is appa- 
rently hard. The artery in such a condition can be rolled under 
the finger. 

The size of the pulse is dependent on the force of the heart, the 
amount of blood in the artery, and the tension of its wall. A 
large pulse (pulsus magnus) is observed in aortic insufficiency, and 
a small pulse (pulsus parvus) in aortic stenosis. Sometimes the 
pulse is so slight as to be thready (pulsus filiformis.) 

The Pulse in Diseases of the Heart. — 

1. Mitral Insufficiency ; no decided departure from the normal. 



92 MANUAL OF CLINICAL DIAGNOSIS. 

2. Mitral Stenosis; pulse small and irregular, frequency 
increased. 

3. Aortic Insufficiency ; pulsus celer, frequency normal or 
increased, usually regular. 

4. Aortic Stenosis ; pulse small, retarded, normal or diminished 
frequency, and regular, as a rule. 

5. Myocarditis ; pul^e small and soft, irregular, frequency nor- 
mal, diminished or increased. 

A comparatively strong pulse, with feeble apex beat and heart- 
tones, is of great value in the diagnosis of exudative pericarditis. 



SPHYGMOGRAPHY. 

This is a method of graphically recording the charac- 
ters of the pulse Dy means of the sphygmograph. 

Normal Pulse Tracing. — (Fig. 9) We notice first an ascending 
line which is straight, and then a descending line which shows 
certain elevations. The ascending and descending lines meet 
above at what is called the summit of the pulse curve. Where the 
ascending line begins and the descending line ends is called the 
base of the curve. The ascending corresponds with the filling of 
the artery ; the descending line with its collapse. The more rapid 
the flow and the more quickly the artery distends the more vertical 
the line. 




Pis. 9. 

Fig. 9. Normal pulse, al. Line of ascent, dl. Line of 
descent, cs. Summit of curve, b. Base of curve, r. Elevation 
of recoil, e' e". Elastic elevations. 

The descending line is broken in its descent by elevations 
which are distinguished as the elevations of elasticity and the 
elevation of recoil. The elevation of recoil is situated about half 
way down the descending line and is produced by the column of 
blood after impinging on the already closed aortic valves, produc- 
ing a new wave. 

The elevations of elasticity are smaller than the elevation of 
recoil (also called dicrotic wave) and are produced by vibration of 
the tense elastic arterial wall. In a normal pulse curve two 
elastic elevations are found, one above the other below the 
dicrotic wave. 



SPHYMOORAPHY. 



93 





Pathological Sphygmographic Tracings.— 

Anacrotic pulse. This is present when elevations are 

found on the ascending line, and 
indicate some abnormality in the 
arterial distribution of the blood. 

It is found in any disease of the 
heart or arteries which allows of only 
spasmodic entrance of blood into the 
latter. 

The greater the decrease in arterial 
tension the more pronounced is the 
elevation of recoil. When the tension 
of the artery is increased (lead colic, 
acute and chronic nephritis) the elastic 
elevations of the artery are pro- 
nounced, and the elevation of recoil 
is but feebly represented. The eleva- 
tions of elasticity may disappear when 
the arterial tension is diminished. 

Dicrotic pulse. This is charac- 
teristic of fever, which decreases 
arterial tension, thus bringing 
into prominence the recoil eleva- 
tion, and causing the disappear- 
ance of the elastic elevations. 

Many forms of dicrotic pulse are 
distinguished: 1. Subdicrotic (when 
the elevation of recoil appears before 
the descending line has reached the 
base of the curve). 2. Dicrotic (after 
it has reached the base of the curve). 
3. Hyper dicrotic (when the recoil ele- 
vation belongs to the ascending part 
of the next wave). 4. Monocrotic 
(when no recoil elevation can be 
recognized.) 

Pulsus tardus (senile pulse). A 
slow ascending line, with round 
and broad summit and no ele- 
vations on the descending line. 
Observed in atheroma of the 
arteries. 

Pulse Curve in Valvular Lesions 
of the Heart. — Aortic Stenosis. The 
ascending line is more sloping owing 
to the retarded entrance of blood into 
the arteries, and the recoil elevation 



Dicrotic Pulse. 



Hyperdicrotic 

Pulse. 



Subdicrotic Pulse. 



Monocrotic Pulse. 

Pulsus Magnus, 

et celer. 

Irregular Pulse in 
dilatation of 
the heart 




Slow Pulse, 
(action of digitalis) 





Pulsus Tardus. 



Fig. 10. 



94 MANUAL OF CLINICAL DIAGNOSIS. 

is absent or imperfectly marked because the arteries are incom- 
pletely filled. Aortic regurgitation : the ascending line is high and 
vertical, the summit pointed and the dicrotic wave absent. Mitral 
lesions: in mitral obstruction, the pulse curve corresponds with 
diminished arterial tension, whereas in insufficiency the tracings 
are varied in relation to the amount of hypertrophy present. 

Pulse Curve in the Veins. — This is the reverse of that in the 
arteries, the ascending line rising slowly, whereas the descending 
line falls quickly. 

In tricuspid insufficiency the venous pulse begins in the diastole 
of the heart and reaches its maximum in the systole, whereas the 
venous pulse occurring with a normal tricuspid valve falls imme- 
diately before the beginning of the systole. The venous pulse in 
tricuspid insufficiency results from the blood wave, which is 
thrown back during the systole of the heart through the insuf- 
ficient orifice into the auricle and thence into the venous system. 

The clinical value of the sphygmograph cannot be denied. It 
not only confirms the evidence obtained by digital examination of 
the pulse, but makes evident certain qualities not appreciated by 
the fingers. It furnishes a record for future reference, and is 
almost indispensable for class instruction. Various modifications 
of Marey's sphygmograph have been introduced, one of the latest 
and best, being that of Ludwig. 



CHAPTER IX. 

THE BLOOD. 

The whole quantity of blood in an adult is about ^ of 
the body weight (10 lbs), whereas in new-born infants it is T ^ of 
the body weight. Specific gravity varies between 1045 and 1075. 
Reaction is alkaline. 

Color of the Blood. — The blood removed from a 
healthy person is lighter when it contains much oxygen 
(arterial) and dark when oxygen is deficient (venous). 

The blood of dyspnoeic persons is very dark. Carbonic oxide 
poisoning, cherry-red color; anaemia and chlorosis (hydremia), 
watery ; leucsemia, pale. 

Haemoglobin. Amount contained in 100 ccm. of blood 
is for man, 13 to 15 grams, in woman slightly less. On 
heating, haemoglobin is resolved into albumen and hsema- 
tin. 

Teichmann's test for blood. Dried blood heated on an object-glass 
with one or two drops of glacial acetic acid to the boiling point to 
which is added a grain of common salt and then slowly evaporated 
will show the formation of brownish-yellow rhombic crystals 
{muriate of hcemcetin) the so-called hozmin. 

Quantitative estimation of haemoglobin can be approximately 
and very satisfactorily determined by means of FleischVs Hcemom- 
eter, which consists essentially of comparing the color of the blood 
dissolved in water with a wedge of colored glass marked in percent- 
ages by an empirically determined scale. The hamioglobinome- 
ter of Gowers, consists of two slender glass tubes, one of which 
contains a preparation of carmine and glycerine jelly, colored to 
represent a dilution of 1 part of healthy blood in 100 parts of water, 
the other tube being: graduated into 100 divisions, each of which is 
equivalent to the volume of blood taken, so that 100 divisions =100 
times the volume of blood. 

The absolute estimation of haemoglobin can only be determined 
by quantitative spectral-analysis. Hcemoglobin is diminished in 
chlorosis, secondary anaemia and advanced cases of leucaemia. 

(W) 



96 MANUAL OF CLINICAL DIAGNOSIS. 

Spectroscopical examination. Examination of the blood 
by means of the spectroscope is of diagnostic importance 
in determining the following : hxmoglobinxmia, carbonic 
oxide and chlorate of potash poisoning. 

Hcemoglobincemia (when the haemoglobin escapes from the corpus- 
cles and is suspended in the blood plasma). Blood removed by 
means of the cupping-glass is allowed to stand in a covered vessel 
for 24 hours. In this time the serum is separated from the clot 
and is yellow in normal blood and ruby-red in hsemoglobinsemia. 
The serum obtained after this method shows in the spectroscope 
two bands in the yellow and green between the d and e lines of 
Frauenhofer. If a few drops of ammon. sulphide are added to the 
solution, the oxyhemoglobin becomes reduced hcemoglobin and 
only 1 band is seen between D. and E. (This is likewise the spec- 
troscopical reaction of normal blood.) 

Carbonic oxide poisoning. Two absorption bands between D and E 
but closer together than in normal blood. The addition of ammon. 
sulphide does not cause their disappearance (because carbonic oxide 
hemoglobin cannot be reduced.) 

Chlorate of potash intoxication. The chocolate-colored blood 
shows, besides the oxy-haemoglobin bands, an absorption band in 
the red of the spectrum. The addition of ammon. sulphide causes 
the disappearance of the 3 bands and the appearance of 1 band 
peculiar to reduced haemoglobin. 



MICROSCOPIC EXAMINATION OF THE BLOOD. 

Method. After providing a clean object and cover glass, cleanse 
the finger thoroughly and, with a needle or a lancet, make a wound 
sufficiently lar^e to admit of the exit of a drop of blood without 
pressure ; place the object glass on the blood drop and adapt the 
cover glass to it without pressure. We find normally in the blood, 
red and white corpuscles and blood plaques (h&matoblasts). In 
disease the corpuscles maybe altered in number and size. 

Oligocythemia (diminution in the number of red blood 
corpuscles). Observed in all forms of anxmia. In 
chlorosis, no diminution in the number of the red corpus- 
cles is observed. Normally, there is in man 5 millions, 
in woman A\ millions of red corpuscles to a cubic milli- 
metre. 

Of all apparatus to determine the number of red blood corpuscles 
that of Thoma-Zeiss is the simplest and best. It consists of a glass 
pipette about 10 cm. long, which contains in its upper third a 
reservoir inclosing a glass bead ; to the upper end is attached a 
rubber tube, which, being placed between the lips, causes the fluid 
to ascend to any desired height by aspiration. The pipette is 



MICROSCOPIC EXAMINATION OF BLOOD. 97 

graduated 0.1, 0.5, 1, and so on to 101. In order to count the cor- 
puscles, suck up with the pipette the escaping blood made by a 
deep puncture in the finger tip, until it reaches the mark 1. The 
point of the instrument is now wiped and the diluting fluid (3 % 
solution of chloride of sodium) is sucked up to mark 101 ; after the 
whole is well shaken, a drop is placed on the counting chamber and 
covered by a cover glass. The counting chamber is fixed to the 
object glass and is T V mm. deep and its floor is divided into 
microscopical quadrates; ^Vo" cubic millimetre being the capac- 
ity of a quadrate. After counting the number of red blood cor- 
puscles contained in 16 quadrates we can easily estimate the 
number contained in a cubic millimetre. If the blood has been 
sucked up to the mark 101, the blood dilution is 1 : 100. The 
number of counted blood corpuscles is first multiplied by 4000 
(rffVff being the cubic capacity of a quadrate) then with 100 (the 
dilution of the blood) ; the product divided by the number of 
quadrates counted, equals the number of corpuscles in a cubic milli- 
metre of blood. The white corpuscles may be similarly counted ; 
the addition of methyl-violet to the diluting fluid causes them, by 
taking up the coloring matter, to become more prominent. 



Yfucleate<S _ 

red blood corpuscles* TofVilocytc** 



T)wa rf 

blood corpuscles,'- 



<kcJi 



A normal ^^^\^)r^ S) r/^ 
red blood - ^0/>K> 

forpusclt* 



Ctanf 

feiood corpuscles* 



iMicrocytcs* 
Fig. 11. 

The Red Blood Corpuscle. — The size of the red 
blood corpuscles may be determined by comparison with 
the blood corpuscles from a healthy individual. 

Macrocytes (Giant blood corpuscles). Found in anaemia 
and progressive pernicious ansemia. 

Microcytes. Exceedingly small, bi-concave red blood 
corpuscles. Found in the blood of anaemic or hydremic 
persons. 



98 MANUAL OF CLINICAL DIAGNOSIS. 

Poikilocytes. Red blood corpuscles of irregular form 
(pear, club or biscuit-shaped and other forms). Found 
in severe anaemia. 

Nucleated Red Blood Corpuscles. Only recognized in 
stained preparations, and found in severe anaemia. 

The White Blood Corpuscle. — The number of 
these corpuscles varies from 5,000 to 10,000 to the cubic 
millimetre and are temporarily increased after a hearty 
meal. The proportion between the white and red in health 
is 1 white to 335 or 600 red blood corpuscles ; and more 
than 1 to 400 must be considered pathological. Not 
more than 5 white corpuscles normally appear in the field 
of vision when high objectives are employed. When more 
than 10 are seen the white corpuscles are increased in 
number. 

Leucocytosis. A moderate increase in the number 
of leucocytes (1 to 100 red). 

Leucaemia. An excessive increase in the number of 
leucocytes (1:50 or even 1:2). 

Ehrlich divides the white blood corpuscles into : (1) Lymphocytes, 
they originate in the lymphatic glands and are about the size of a 
red corpuscle with a large round nucleus and little protoplasm. 
(2) Monocular leucocytes, larger than the red corpuscles with large 
oval nucleus and large protoplasmic body. They are the earlier 
stages of the development of the third. (3) Polynuclear leucocytes, 
they contain a divided nucleus and are deeply stained with aniline 
colors. (4) Eosinophilous cells, leucocytes containing in their 
protoplasm fatty granules which are colored an intense red on 
staining the dried blood with a 1 % watery solution of eosin. The 
eosinophilous cells originate in the marrow of bones. In myelo- 
genetic leuccemia they are very much increased being present in 
normal blood only in very small numbers. The lymphocytes are 
increased in leucaemia of lymphatic origin. 

In all cases of leucocytosis the monocular and polynuclear cells 
are increased in number, but the eosinophilous cells are not. 
In leucaemia the eosinophilous cells are increased in number ; so 
in doubtful cases of leucaemia the diagnosis can often be made 
by finding the eosinophilous cells. 

Blood-plaques (hcematoblasts). — These are colorless flat round 
discs about one-half the diameter of a red blood corpuscle. They are 
supposed to take an active part in coagulation. They may be 
demonstrated as follows : A drop of a solution of methyl-violet (1 to 
5,000) is placed upon a punctured wound of the finger and mixed 
with the blood which is examined with high objectives. 

Method of Staining Blood Specimens. — After puncturing the 
finger, place a drop of blood between two cover glasses and spread 



MICROSCOPIC EXAMINATION OF BLOOD. 99 

it out in a thin film ; next separate cover glasses and expose to the 
air until thoroughly dry. Then fix the haemoglobin by heating the 
cover glasses for a few hours at a temperature of 212° F. ; this 
may be accomplished by putting the glasses on a metal plate 
to one corner of which the heat may be applied. It is now ready 
fur coloring and the following solution is usually employed. 

Hematoxylin, 2 grams. 

Alcohol, 

Glycerine, 

Distilled water, aa 100 grams. 

Glacial acetic acid, 10 grams. 

Alum in excess. 

This solution is exposed to the light for 3 weeks and a fev. 
grains of eosin added. The cover glasses remain in the solution 
for 30 minutes and are then washed in water. The red blood 
corpuscles are stained red, the nuclei of the white and red corpus 
cles intensely black, the eosinophilous granules, red ; whereas the 
protoplasm of the white blood corpuscles is only feebly stained. 

The stained preparation is examined with the oil immersion. 

Melansemia. Dark pigment scales either floating free 
in the blood or enclosed by amceboid movements of the 
white blood corpuscles. These scales may be deposited 
in the viscera. They are probably liberated by the disin- 
tegration of the red corpuscles and are found immediately 
after severe attacks of malaria. 

Micro - organisms in the Blood. — 1. Bacillus 
anthracis. May be present in the blood in splenic fever 
(malignant pustule, carbuncle) and is the sole cause of 
the affection. 

The bacilli anthracis can usually be demonstrated 
without staining as immobile thick rods as long or twice 
as long as the diameter of a red blood corpuscle. 

Spirochsete Obermeieri (spirillum). The spirilla are 
found in relapsing fever (febris recurrens) only during 
the febrile attacks in very large numbers and are the 
cause of the disease. They are long fine spiral fibres 
about 6 to 7 times the diameter of a red blood corpuscle 
in length, and are endowed with rapid movement. Their 
presence according to Gunther may be demonstrated as 
follows : The blood specimen prepared in the usual way 
on the cover glass is exposed for 10 seconds to a 10% solu- 
tion of acetic acid in order to decolorize the red blood cor- 
puscles, now remove the cover glass from the former 



100 MANUAL OF CLINICAL DIAGNOSIS. 

solution and blow the acid off with a pipette. Stain 
with a saturated solution of gentian violet in aniline 
water. 

Bacillus Tuberculosis. May be found in the blood in 
cases of acute miliary tuberculosis. For detecting them, 
see Sputum. 

Bacillus Typhosus. Often found in the blood in typhoid 
fever. It is a short (£ the diameter of a red blood corpus- 
cle) thick rod with rounded ends. 

Bacillus Mallei (glanders). Has been frequently found 
in this disease. 

Plasmodium Malarice. This organism is found in the blood in 
malaria inclosed in the red corpuscles as an amoeboid mass fre- 
quently containing black pigment. The organism is best stained 
with methyl-blue. Whereas the etiology and biology of this organ- 
ism is not definitely known, it has tnus far only been discovered 
in the blood in malaria and its detection is of diagnostic importance 
in doubtful cases. 

Animal Parasites (Haematozoa) in the Blood. — Dutoma Hcema- 
tobium. Occurs in the tropics and lives in the abdominal veins. 
It causes diarrhoea, hematuria and chyliiria. 

Filaria sanguinis hominis. 

Chemical Changes in the Blood.— The alkalinity of the blood is 
diminished in severe anaemia, high fever, and diabetes. Urea 
may be increased in the blood in insufficiency of the kidneys. 
Uric acid is increased in gout. Normally uric acid is not demon- 
strable in the blood ; but during and preceding the attack of gout it 
is greatly increased (0. 25 — 1.75%.) Garrod's method of detect- 
ing uric acid in the blood is as follows : To the fluid contents of a 
blister placed in a watch glass add 6-12 drops of diluted acetic 
acid (30%), then introduce into fluid a cotton fiber and let it 
remain for 24 hours, when, if uric acid is present, the crystals are 
deposited on the fiber and may be recognized by the microscope. 

The blood after removal from the body is variously influenced 
in the rapidity of coagulation by different diseases. In health 
coagulation begins in about 9 minutes and is accelerated in chronic 
disturbances of nutrition. Fine fat granules are present in the 
blood (Lipamia) in chyluria, diabetes and alcoholism. In 
diabetes mellitus the sugar (present in minimum quantities in 
normal blood) is increased. 

Cholcemia. Biliary acids and pigment in the blood ; the former 
dissolve the red corpuscles. 

Uramiia. Accumulation of urinary constituents in the blood. 
The theory that urea is the essential toxic agent is no longer 
accepted. 



DISEASES OF THE BLOOD. 101 



DISEASES OF THE BLOOD. 

Secondary Anaemia. — Observed in tuberculosis, 
severe dyspepsia, malaria, syphilis, carcinoma, ankylos- 
tomiasis (see anchylostomum duodenale), lead poisoning, 
nephritis, etc. The number of red blood corpuscles and 
the amount of haemoglobin is diminished. The number 
of leucocytes is increased (leucocytosis). Secondary, may 
pass into pernicious anaemia. 

Progressive Pernicious Anaemia. — The number 
of red corpuscles is enormously reduced (a cubic milli- 
metre may contain only 400,000) to a degree rarely 
attained even in the severest form of ordinary anaemia. 
Poikilocytes, macrocytes and microcytes are seen. The 
important diagnostic condition is the relative increase in 
the blood, of haemoglobin. Prognosis is usually bad. 

Chlorosis. — Observed usually in young girls. The 
essential condition is a great reduction in the amount of 
haemoglobin, without reduction in the number of red, or 
an increase of white corpuscles. Poikilocytes may be 
present. Prognosis is usually good. 

Leucocytosis. — This is a condition characterized by 
a temporary increase in the number cf white blood 
corpuscles. Such an increase is physiological from 1 to 
2 hours after the principal meal, when the relation to the 
red corpuscles maybe 1:150 or even 1:100 (usual relation 
varies from 1:335 to 600). Leucocytosis is observed in 
many acute (pneumonia, erysipelas) and chronic diseases 
(carcinoma). In this affection the eosinophilous cells 
are not increased in number. 

Leucaemia. — The white corpuscles are increased in 
number, the proportion of white to red exceeding 1:50 
(the proportion may even reach 1:2).. In the earlier 
stages of the disease it can only be diagnosed by the very 
rapid increase of leucocytes. Eosinophilous cells only 
occur in leucaemia. The number of red corpuscles and 
the amount of haemoglobin is diminished. Crystals, like 
the asthma crystals (see Sputum) are sometimes found 



102 MANUAL OF CLINICAL DIAGNOSIS. 

in the blood. The following forms of leucaemia are 
differentiated : 1. Lymphatic leucsemia ; lymphocytes 
increased and lymphatic glands enlarged. 2. Myelogenic 
leucsemia; eosinophilous cells, mononuclear cells, and 
nucleated *red corpuscles are present and the bones 
(especially sternum and vertebrae) are painful on pressure. 

Splenic (lienal) leucsemia: Blood appearance like the 
former and the spleen is enlarged. These forms are not 
always distinct and may be combined. The prognosis 
is usually bad. 

Pseudo-leucaemia (Hodglirts disease). — An affec- 
tion characterized by cachexia, enlargement of the spleen 
and lymphatic glands. The leucocytes are not increased, 
although there is a slight decrease in the number of red 
corpuscles and in the amount of haemoglobin. 



CHAPTER X. 

THE DIGESTIVE SYSTEM. 

Odor from the mouth (fcetor ex ore) is observed in caries 
of the teeth, dyspepsia, etc. In lead, phosphorus, alcohol 
and chloroform intoxication the odor is often diagnostic. 
In diabetes, especially before or during diabetic coma the 
odor is likened to that of fresh apples. 

The Lips. — The color acquaints us with the condition 
of the blood. Dryness and formation of crusts are 
observed in fever. In children rhagades at the angles of 
the mouth are characteristic of hereditary syphilis. 

The Teeth. — In diabetes mellitus caries of the teeth 
may be pronounced. Bad teeth often lead to affections 
of the stomach. Notched teeth, keratitis, fissure at the lips, 
and mucous tubercles at the anus or mouth are characteris- 
tic symptoms of congenital syphilis. The teeth are loose in 
scorbutus and mercurial intoxication. 

FORMULA OF THE MILK TEETH.— (Finlayson.) 
M 2 0, I, d M 2 | go in all 

TIME OF APPEARANCE. 

Central incisors 7th month 

Lateral incisors 9th u 

First molars 15th " 

Canines 18th " 

Second molars 24th " 

FORMULA OF THE PERMANENT TEETH. 

Ms B 2 O t I, C t B 2 M 3 [ 32 in all 
M.B.UxI^CiBaM.i 

(108) 



104 MANUAL OF CLINICAL DIAGNOSIS. 

TIME OF APPEARANCE. 

Anterior molars 7th year 

Central incisors 8th " 

Lateral incisors 9th M 

Anterior bicuspids 10th " 

Posterior bicuspids 11th M 

Canines 12th " 

Second molars 12th to 14th u 

Third molars 18th to 25th " 

The Gums. — Spongy with submucous haemorrhages 
in scurvy; swelling of the gums with salivation in mercu- 
rial poisoning. Blue or blackish line on the gums just 
above the teeth occurs in lead-poisoning. A red line on 
the gums is considered characteristic of a phthisical 
constitution. 

The Tongue. — Coated in catarrhal affections of the 
stomach although in ulcer of the stomach and hyper- 
acidity this is not usual. Soft white patches (Muguet, 
Thrush) due to the vegetation of the oidium albicans may 
be present; most often seen in children but likewise in 
adults suffering from exhausting diseases. The vegeta- 
ble parasite may be seen with the microscope after remov- 
ing the spots and adding liquor potassse. 

The tongue is enlarged in the different forms of stomatitis, 
inflammation (Glossitis), etc. Circumscribed swellings maybe due 
to syphilis or carcinoma. Wounds and cicatrices on the tongue 
occur in epilepsy. In hystero- epilepsy wounding of the tongue 
rarely occurs. 

Tremor in alcoholism and typhoid fever. 

Strawberry tongue in scarlatina. 

Saliva is an alkaline fluid (about 2j£ pounds secreted in 24 
hours), with a specific gravity of 1,002 to 1,006. It sometimes 
contains sulphocyanide of potassium ( SCNK) which is recognize! 
by adding a few drops of hydrochloric acid and a diluted solution 
of chloride of iron ; a blood-red color appears, which is taken up 
on shaking with ether. Saliva may be further recognized by 
adding to it some diluted starch-paste and maintaining it at the 
body temperature for a few minutes when the conversion of starch 
into sugar can be shown by the usual test for the latter. 

Saliva is increased {Salivation, Ptyalism) in all irritations of the 
mouth, after the use of mercury and in bulbar paralysis. Dimin- 
ished in fever, diabetes, diarrhoea, etc. .Reaction is acid in 
stomatitis and diabetes. 

The Fauces. — Large tonsils with deep follicles indicate previ- 
ous inflammations ; prominent whtte cicatrices, syphilis. Chronic 



EXAMINATION OF (ESOPHAGUS. 105 

ulcers on tonsils may be tuberculous or, more often, syphilitic in 
character. Retropharyngeal abscesses may form between the phar- 
ynx and the bodies of the vertebrae. 

AncESthesia of the throat is present in hysteria and alcoholism. 
Hyperesthesia also present in drunkards. 



EXAMINATION OP THE (ESOPHAGUS. 

Anatomy of the (Esophagus. — It commences at the lower border 
of the cricoid cartilage (opposite the 5th cervical vertebra), corre- 
sponding to the base of the xiphoid appendix, it terminates at 
the cardiac orifice of the stomach. It presents two or three slight 
curvatures in its course. At its commencement it is in front of 
the vertebral column, but inclines to the left of the column as 
far as the root of the neck, gradually passes in front of the column 
again, and finally, again deviates to the left as it passes forward 
to the oesophageal opening of the diaphragm. The average 
length of the oesophagus in adults is about 25 cm. (10 inches). 
Measurements of the oesophagus are usually reckoned from the 
upper incisor teeth. The distance from the upper incisors to 
the beginning of the oesophagus is about 15 cm. (6 inches). The 
distance from the incisor teeth to a point in the oesophagus oppo- 
site the bifurcation of the trachea is about 22 cm. (9 inches). The 
distance to the cardiac orifice of the stomach from the incisor teeth 
is in infants about 17 cm. (7 inches), and in adults about 40 cm. 
(16 inches). The narrowest parts of the oesophagus are at its 
commencement and at the point where it passes through the 
diaphragm. 

The important neighboring structures of the oesophagus are : 
trachea, bronchial glands, pleura, pericardium, aorta (from the 
bifurcation of the trachea downwards), and the inferior laryngeal 
nerve (from the bifurcation of the trachea upwards.) 

Methods of Examination : Inspection, Palpation, 
Percussion, Auscultation. 

Inspection is usually limited to the neck portion of 
the oesophagus. Tumors and diverticula may be noted. 
For internal inspection of the oesophagus, a method 
known as cesophagoscopy has been introduced but with 
results negativing its universal practical application. 

Palpation. — The finger introduced into the mouth 
cannot reach the oesophagus. Mediate palpation with 
sounds is the most important method of examination. 

Introduction of Sound. — The sound must first be lubricated with 
glycerine (not oil). The patient sits on a chair with the head 
elevated ; introduce the index: and middle ringers of the left 
hand into the mouth of the patient down to the root of the tongue, 



106 MANUAL OF CLINICAL DIAGNOSIS. 

and with the sound grasped in the right hand, direct it to the ends 
of the fingers in the mouth, and with the ends of the fingers direct 
the tip of the sound downwards, and by elevating the right hand 
push it slowly in the same direction. Physiological resistance to 
the introduction of the sound is met with at the following points . 

1. Wall of the pharynx. 2. At the commencement of oesopha- 
gus. Resistance is also encountered owing to the contraction of 
the oesophageal musculature (disappears after waiting a short 
time). 

Dangers in the Introduction. — 1. Perforation of the trachea 
(seldom). 2. Wounding or perforating the oesophagus. Abscesses 
and aneurism adjacent to the oesophagus may be penetrated by 
injudicious manipulation of the sound. Never employ strong 
pressure with the sound when a resistance is encountered, and 
always use smaller sizes if the larger will not pass. 

In examinations with the sound pain, the presence of 
diverticula, narrowing and dilatation are noted. 

Pain. May be produced by inflammation, ulceration or 
involvement of structures adjacent to the oesophagus. 

Diverticula. When they are present the sound may at 
one sitting pass through the oesophagus and at another 
time it may meet with an obstruction. 

Narrowing. The seat and degree of narrowing is deter- 
mined. The seat of the narrowing (stricture) can readily 
be determined by measurements from the upper incisor 
teeth. The degree of narrowing is determined by the 
size of sounds necessary to pass the stricture. The nature 
of the narrowing may occasionally be determined by 
particles of tissue remaining attached to the sound after 
removal. 

Dilatation is present above strictures and in paralysis 
of the musculature of oesophagus. 

Percussion is only of very limited application. Diverticula in 
the cervical portion of the oesophagus when filled give a dull 
sound. If they are situated deeper, a dullness maybe obtained 
along side the vertebral column. V. Ziemssen made dilatations 
of the oesophagus above the stricture evident by artificial 
distension with bicarbonate of soda and tartaric acid (which in 
combination yield carbonic acid gas) and obtaining in consequence 
a tympanitic or tympanitically dull sound over the diverticulum. 

Auscultation is of little practical value. 

A short murmur immediately after swallowing is heard over the 
entire course of the oesophagus during health. In stricture, this 
murmur may be delayed, weakened or absent. A longer murmur 
heard in the epigastric region about^ 7 seconds after swallowing 
(murmur of Kronecker and Meltzer) is of less importance. 



EXAMINATION OF THE STOMAC&. 



107 



EXAMINATION OF THE STOMACH. 

Topography of the Abdomen. — If two circular lines are drawn 
round the body the one parallel with the cartilages of the 9th ribs, 
and the other with the highest points of the crests of the ilia, the 
abdominal cavity will be divided into three zones, upper, middle 
and lower. These zones are further divided by two parallel lines 
drawn from the cartilage of the 8th rib on either side down to the 
center of Poupart's ligament. Thus the three zones are subdivided 
into a middle and two lateral parts. 





MIDDLE REGION. 


LATERAL REGIONS. 


Upper Zone. 


Epigastric 


Right and left hypochon- 
driac 


Middle Zone. 


Umbilical. 


Right and left lumbar. 


Lower Zone. 


Hypogastric 


Right and left inguinal 



Anatomy of the Stomach. — Nearly the entire stomach lies to 
the left of the median line with the exception of the pylorus 
which is to the right of this line. The fundus lies under the left 
leaflet of the diaphragm extending as high up as the 4th inter- 
costal space. The pylorus lies between the right sternal and 
parasternal lines, at the height of the tip of the ensiform 
cartilage. The cardiac orifice lies behind the sternal attachment 
of the seventh rib. The lesser curvature of the stomach and the 
pylorus are covered by the left lobe of the liver. The greater cur- 
vature in health rarely attains the umbilicus, being as a rule 
about 1 inch above the latter. That portion of the stomach which 
is uncovered by organs and directed to the surface of the chest 
and abdomen lies in the half moon shaped space of Traube. 

INSPECTION AND PALPATION. 

Normal condition. Inspection of the region of the 
stomach rarely shows any departure from the normal. 
After distension of the stomach by food a slight prom- 
inence in the epigastric region is noted. 

Pathological Conditions : Pain, dilatation of the 
stomach, thickening of the stomach, increased peristaltic 
action of the stomach, and circumscribed tumors. 

Pain. On pressure it may be absent in all diseases of 
the stomach. It may be circumscribed or diffuse. In 



108 MANUAL OF CLINICAL DIAGNOSIS. 

acute and chronic catarrh of the stomach, pain if present is 
diffuse. In ulcer of the stomach, the pain is circumscribed. 
In order to render the stomach wall palpable it is often 
necessary to distend the stomach with carbonic acid gas. 
This is done, according to Frerkhs, by administering a 
teaspoonful of bicarbonate of soda and of tartaric acid as 
separate doses, in water. 

As this method of inflation often leads to dangerous results, it 
can be replaced with success by a method of recent introduction. 
This consists of introducing a stomach sound, through which 
air is forced in any desired quantity into the stomach. 

If after the administration of bicarbonate of soda and tartaric 
acid no inflation of the stomach, but of the intestines occurs, then 
incontinence of the pylorus most likely exists. Incontinentia pylori 
may be functional or occasioned by destruction of the muscular 
tissue of the pylorus by carcinoma or ulceration. 

Dilatation of the Stomach. When this is present inspec- 
tion often shows a prominence in the upper part of the 
abdomen extending down to or below the umbilicus. 
Palpation may define the size of the stomach by its 
peculiar resistance. Of greater importance is the produc- 
tion of a splashing noise on palpation. Leube at one time 
determined the size of the stomach, by means of a sound, 
the point of which after introduction into the stomach was 
felt through the abdominal walls. He no longer practices 
this method, relying on percussion as a more certain means 
of diagnosis. 

Thickening of the Stomach. This is determined by 
increased resistance on palpation ; present in hypertrophy 
of the musculature of stomach, a condition often accom- 
panying dilatation. Circumscribed thickening should 
always awaken the suspicion of carcinoma ; but con- 
traction of the abdominal muscles must be excluded. 

Increased peristaltic action is determined by inspection 
and palpation. The movements of the stomach are 
usually directed from the cardiac orifice to the pylorus, 
at other times the peristaltic movements are irregular. 
They may occur spontaneously or must be induced by 
percussion or faradization of the abdomen. Increased 
peristaltic action is most frequently observed in stenosis 
of the pylorus, which leads to dilatation, and hypertrophy 



EXAMINATION OF THE STOMACH. 109 

of the musculature of the stomach. Kussmaul has 
shown that increased action may be purely a neurosis. 

Circumscribed tumors are more often felt than seen. 
They usually indicate carcinoma of the stomach, and 
rarely, a cicatrized ulcer. Hypertrophy of the muscular 
coat of the stomach may lead to a circumscribed intum- 
escence, but unlike carcinoma, which is hard with an 
uneven surface, it is smooth and less resistant. 

Carcinomata of the stomach are seldom influenced by respira- 
tion unless adhesions exist between them and the liver, the respi- 
ratory movements of the latter being communicated to the 
tumor. Foreign bodies in the stomach and scybala in the colon 
may be confounded with tumors, but the differential diagnosis is 
usually easy. 



PERCUSSION OF THE STOMACH. 

The only portion of the stomach which can be percussed 
lies in the left hypochondriac and epigastric regions and 
comprises a part of the anterior wall. In order to define 
the stomach by percussion, the dullness of the liver is 
first determined to the right, the resonance of the lung 
to the left and above, and the tympanitic sound of the 
colon below. Between these organs the stomach gives 
a deep tympanitic sound which is with difficulty distin- 
guished from the high tympanitic percussion note of the 
intestines. The size of the stomach is usually determined 
by percussing the lower border of the greater curvature, 
remembering that when it reaches below the umbilical 
line, the stomach is considered dilated. Percussion is 
best practised after inflation of the stomach, but as 
carbonic acid gas which is used for this purpose is dan- 
gerous we adopt the following method: 

Introduce the stomach tube, remove the stomach contents and 
percuss abdomen while patient is standing ; as a rale the boundary 
of the stomach cannot be made out; now introduce through the 
tube into the stomach about two pints of water and percuss again ; 
a dullness is obtained, which disappears on removal of the fluid or 
when the patient lies down. In health, this dullness which repre- 
sents the lower border of the stomach never reaches the umbilicus. 



110 MANUAL OF CLINICAL DIAGNOSIS. 

AUSCULTATION OF THE STOMACH. 

Murmur of Deglutition. This is a murmur, normally 
heard in auscultating the epigastric region, occurring 
from 6-7 seconds after swallowing fluid. In insufficiency 
of the cardiac orifice (present in syphilis and phthisis) 
the murmur is heard immediately after swallowing. It 
is absent in obstruction at or above the cardiac orifice. 

Splashing Noise. This is heard when fluid and gas are 
present in the stomach. It may denote a normal con- 
dition, but is frequently present in dilatation of the 
organ. 

A sound likened to that of boiling water may be heard in 
fermentation of the contents of the stomach. 

Oastroscope. This is an instrument used for the purpose of 
inspecting the interior of the stomach but it is not always adapted 
for practical use. 



THE CHEMICAL ANALYSIS OF THE STOMACH AS A 

MEANS OF DIAGNOSING GASTRIC 

DISTURBANCES.* 

Gentlemen : In the brief period of time at our disposal we can 
only, succinctly, review the late methods of diagnosis in diseases 
of the stomach. The artificial removal of the stomach contents 
is the only certain means of determining the character of the 
secretion and the degree of digestion. The removal of the gastric 
contents is best accomplished by the aid of the soft rubber tube, 
which I show you, working on the syphon principle. The intro- 
duction of the tube is simple. You ask the patient to make 
efforts at deglutition, and then gently and rapidly pass it into the 
stomach, which, when reached, is indicated by a black band on 
the tube. The real difficulty with which you will most frequently 
contend is the nausea and vomiting induced by the introduction 
of the tube. This sensitiveness of the fauces was formally combat- 
ed by administering bromide of potassium for a few days before the 
introduction of the tube. This develops a moderate anaesthesia of 
the throat and diminishes the reflexes. A better method of prepar- 
ation is that of painting the palate and the fauces with a solution 
of cocaine and lubricating the tube with a mixture of the same 
solution and olive oil. A difficulty in breathing is often com- 
plained of by the patient, which you can alleviate by asking him 
to take as deep breaths as possible. 

♦Clinical lecture by Albert Arrams. Reported by Ernest Johannsen. 
Reprinted from Occidental Medical Times, April, 1889. 



ANALYSIS OF THE STOMACH. Ill 

You will now ask the patient to cough violently or, if this does 
not suffice, to forcibly compress his abdominal muscles, when a 
sufficient amount of 'fluid for chemical analysis will usually be 
ejected from the tube. If then no fluid returns, connect your 
tube with a funnel, introduce some water into the latter, then 
hold the funnel ov«r the patient's head until the water enters the 
stomach, but before all the fluid has left the funnel, lower it 
quickly and you will then get the contents of the stomach, plus 
water. Particles of food may stop up the orifice of the syphon. 
When this is suspected ask the patient to cough, or pour more 
fluid into the funnel, which will renew the suction action of the 
syphon. 

After the ingestion of a meal, there is first a digestive period 
called the amylolytic, which lasts, on an average, three-quarters 
of an hour. After this time free hydrochloric acid is present, the 
amylolytic digestion ceases, and a peptonization of the albumen 
begins. The maximum degree of acidity (0.15 to 0.2 per cent, of 
hydrochloric acid) is attained about five hours after eating. Dur- 
ing the entire period of digestion, the contents of the stomach, by 
Eeristaltic action, slowly pass into the duodenum. About six 
ours after eating, the stomach should be practically empty, and 
its contents 6hould possess a neutral reaction. A diminished 
amount of gastric secretion interferes with the digestion of albu- 
men, an excess (hyperacidity) interferes with amylolytic digestion, 
as the latter can only occur in the absence of free hydrochloric 
acid. 

For the purpose of determining the duration of digestion I have 
given this patient a meal composed of soup, bread and beefsteak. 
Lavage of the stomach practiced seven hours after consuming such 
a meal would show, in normal digestion, that organ to be prac- 
tically empty or containing a few fragments of food: under these 
conditions we would conclude that digestion is normal. We could 
further assume that there is probably no diminution of secretion, 
and absolutely, that the stomach has no difficulty in emptying 
itself. {Should the stomach seven hours after the ingestion of a 
meal contain a considerable amount of food, then digestion is 
delayed or the viscus has some difficulty in emptying itself. This 
difficulty may occur in dilatation, in stenosis of the pylorus or 
when the motor activity of the stomach is impaired. After the 
duration of digestion has been determined, it will be well to study 
the contents during digestion, and the best time for this purpose 
is about one and one-half hours before the stomach is empty, a 
time at w r hich. you w r ill remember, the degree of acidity is at its 
maximum. We filter the fluid which has been removed and 
proceed to examine as follows : 

The reaction is first determined with litmus paper, and we find 
it acid. An acid reaction may depend upon the presence of hydro- 
chloric acid , or organic acids. I will first make the various tests for 
hydrochloric acid, of which there are many. The first, to which I 
will call your attention, is, that with methyl-violeU Two test tubes 
are filled with an aqueous solution of methyl-violet, the solution 



112 MANUAL OF CLINICAL DIAGNOSIS. 

being reddish-violet. To the one is added some of the gastric 
fluid, the other being used for comparison; should hydrochloric 
acid be present, the solution becomes distinctly blue. Organic 
acids will also render the solution blue, when in sufficient concen- 
tration, which, however, doe3 not occur in the stomach. This is 
one of the oldest tests, and is very uncertain, as no reaction will 
occur in the presence of peptones or phosphates, and on the other 
hand, the presence of sodium chloride may yield the same reac- 
tion as that of hydrochloric acid. The second test is that with a 
solution of tropeolin, a few drops of which, when mixed with the 
gastric solution on a porcelain plate and heated, will yield a 
violet-red color. Another test is that with a solution of congo red 
in water, which turns blue in the presence of the acid. Filtering 
paper saturated with the congo solution serves as a ready test ior 
the acid. A useless test is that with a solution of fuchsine, which 
becomes decolorized in the presence of the acid. The most certain 
and simple test for hydrochloric acid is that of Gunzberg. Albu- 
minoids and organic acids will not interfere with the reaction, and 
the smallest quantity of the acid may be determined. The 
phloroglucin-vanillin solution, which is the fluid used by Gunzberg, 
is composed of 2 parts of phloroglucin and 1 part of vanillin to 30 
parts of alcohol ; a few drops of this when mixed with a similar 
quantity of the gastric solution and heated on a porcelain plate, 
will yield a red precipitate in the presence of the hydrochloric 
acid. From the intensity of the red color, we can determine 
approximately the quantity of acid present, the intensity of the 
redness being in direct proportion to the amount of acid. 

We next determine the presence of the organic acids, and for 
all practical purposes it will suffice, if we test for lactic, butyric 
and acetic acids. A solution composed of 3 drops of liquor ferri 
perchloridi, with the same quantity of carbolic acid, in 20 cubic 
centimeters of water, shows the presence of lactic acid by becom- 
ing yellow ; but if free hydrochloric acid is present the solution 
becomes colorless. Butyric acid can be recognized by its odor, 
that of rancid butter, and will also turn the latter solution yellow. 
Acetic acid is also determined by its odor, and when boiled in a 
test tube with the chloride of iron carbolic acid solution, will turn 
the latter a brownish co^or. The quantitive determination of 
hydrochloric acid* is of importance, and consists essentially of 
adding a -rV normal sodium hydrate solution to the gastric 
secretion, 1 c. cm. of the former neutralizing 0.00365 of hydro- 
chloric acid. Whenever the amount of hydrochloric acid is more 
than 0.3 per cent., it must be considered pathological. The 
qualitative determination of peptone t is without diagnostic 

* Let us suppose that 5.6 ccm. of soda solution was necessary to neutralize 
10 ccm. of the filtered gastric fluid, then the following calculation will give 
the percentage of hydrochloric acid: 1 ccm. of the soda solution will neu- 
tralize .00365 of hydrochloric acid ; now if 5.6 ccm. of soda solution was 
necessary to neutralize 10 ccm. of gastric fluid, then 56 ccm. would be neces- 
sary to neutralize 100 ccm. 56 X .00365 = .204% of hydrochloric acid. 

+" Reaction for peptone. A little of the gastric fluid is rendered strongly alka- 
line, and a dilute solution of cupric sulphate is added drop by drop; a red 
color. 






ANALYSIS OF THE STOMACH. 113 

importance, and the same may be said of ptpdne,* which is 
never absent when free hydrochloric acid is present. 

What conclusions may we arrive at after making these tests ? 
We lind hydrochloric acid absent in atrophy and amyloid degen- 
eration of the gastric mucous membrane, which affections are rare, 
and also in fevers. We find it absent in the majority of cases of 
dilatation of the stomach due to carcinoma of the pyloric orifice, 
and in a few instances of so-called nervous dyspepsia. The 
absence of hydrochloric acid when dilatation of the stomach 
exists, is almost an absolute sign of carcinoma, although the 
normal acid reaction, and even hyperacidity, have been found in 
a few isolated cases, attended by dilatation of the stomach. Lactic 
acid is normally found in the stomach, but not longer than one 
hour after eating. It originates from grape sugar, by the action of 
microorganisms, the sugar as you know being a product of the 
starch from amylolytic digestion. Now, when lactic acid is found 
in the stomach at a longer interval than one hour after eating, it 
indicates abnormal fermentation, and in the majority of cases is 
present when hydrochloric acid is deficient or absent. Hyperaci- 
dity of the gastric secretion often occurs in ulcer of the stomach, 
and in certain forms of nervous dyspepsia. 

The determination of the motor activity of the stomach, by 
means of salol, calculated by the time consumed in the appear- 
ance in the urine of salicylic acid, or the recent method of 
Klemperer, by measuring the quantity of its contents discharged 
into the intestine in a given time, are superfluous. For the 
practical physician, the motor activity is best determined by 
washing out the stomach seven hours after eating, when, if nothing 
is found, it indicates the sufficiency of the muscular tissue. 

Let me, in conclusion, refer to a method of determining the 
absorptive power of the stomach. You direct the patient to 
swallow, on an empty stomach, a gelatine capsule, containing 0.1 
gm. of iodide of potassium. You then have him expectorate 
on a piece of starched paper. The addition of a few drops of 
fuming nitric acid, if iodine is present, will give a red color, and 
if the iodine be in excess, a blue color. In normal cases it has 
been found that the absorption is accomplished in from eight to 
fifteen minutes. In chronic catarrh, absorption was found to be 
delayed for thirty minutes, and in carcinoma for three to four 
hours. 

* The digesting capacity of the gastric fltiid is tested as follows: To two test tu&ct 
containing: the fluid, a bit of washed fibrin is added, and to one of the tubes 
a fpw drops of 1% hydrochloric acid, and both tubes are placed in a water 
bath at body temperature, if after 6-12 hours the fibrin in neither tube is dis- 
solved, pepsine is deficient; if the fibrin in tube containing the acid is alone 
digested, then the gastric fluid contains pepsine, but no hydrochloric acid. 
Normally the fibrin in both tubes should disappear in 1-2 hours. 

M. C. D. 8 



114 MANUAL OF CLINICAL DIAGNOSIS. 



DIAGNOSIS OP DISEASES OP THE 
STOMACH. 

Acute Gastric Catarrh (symptoms of dyspepsia). — 
Nausea, no appetite (anorexia) coated tongue, bilious 
vomiting, slight epigastric pain, little fever, thirst, vertigo 
in the morning, headache, etc. 

Examination of vomit shows deficient hydrochloric acid; 
lactic acid and mucus in excess. 

Chronic Gastritis. — Early morning vomiting of 
glairy mucus and exaggeration of the symptom complex 
of the previous disease. Atrophy of the mucous membrane 
of the stomach and dilatation of the organ are sequelae of 
the affection. In atrophy, when the contents of the stomach 
are removed, hydrochloric acid, or mucus, is not present. 

Gastric Ulcer. — Frequent in women (anaemia). 
Symptoms of dyspepsia. Fixed pain (varying in inten- 
sity according to position of patient). Vomiting after 
taking of food. Haematemesis in about ■£ the cases. An 
excess of hydrochloric acid is almost constant. 

Gastric Cancer. — Occurs in advanced life. Symp- 
toms of dyspepsia ; emaciation and cachexia ; pain is 
severe and independent of the introduction of food; 
vomiting occurs immediately after eating if the cancer is 
at the cardiac orifice ; if at the pylorus, it occurs several 
hours after eating. Haematemesis in about \ the cases. 
Tumor in about 80% of the cases. Hydrochloric acid 
usually absent. 

Duration of disease; 1 to 5 years. 

Dilated Stomach. — Symptoms of dyspepsia. Habit- 
ual vomiting of enormous masses containing a number of 
parasites (sarcina ventriculi, bacteria, etc.) 

Lower border of the stomach reaches below the umbili- 
cus. Constipation, skin dry, emaciation and diminished 
secretion of urine. 

Cause of dilatation must be determined ; may be due to 
stricture of the pylorus (ulcer cicatrix or carcinoma) or 
atony of the stomach. 



VOMITING. 115 

Nervous Dyspepsia. — Pronounced dyspeptic symp- 
toms, notwithstanding physical examination of the stom- 
ach and its contents show nothing abnormal. Nervous 
symptoms in other parts of the body. 



VOMITING. 

Vomiting consists in contractions of the abdominal muscles 
and diaphragm while the pylorus is closed and the cardiac 
orifice is open. 

The vomit center in the medulla is irritated directly {central 
vomiting) or indirectly (reflex vomiting) by means of the sensory 
fibres of the vagus. Children vomit more easily than adults. 

Forms of Vomiting : 1. Reflex from the stomach, 
occurs in nearly all diseases of this organ, from the action 
of poison, emetics, etc. 2. Reflex from the abdominal 
viscera; female sexual organs, peritonitis and affections 
of the kidneys. 

Under this head may be mentioned throat irritation 
and vomiting after paroxysms of coughing. 

3. Central Vomiting : Diseases of the brain and 
meninges, uraemia and at the beginning of infectious 
diseases (pneumonia, scarlatina, variola, etc.). 

Vomiting is accompanied with nausea, pallor, increased pulse 
frequency and sweating. Spontaneous Vomiting not preceded by 
nausea is characteristic of some brain affection. 

In uraemia, the vomit has an, ammoniacal odor. Periodical 
vomiting occurs as the gastric crises in affections of the spinal cord 
notably tabes. Vomiting before breakfast (vomitas matutinus) is 
an early symptom of potation, the vomit consisting of salvia 
unconsciously swallowed during the night. Severe and pei'sisfer/t 
vomiting unaccompanied by diseases of the stomach or abdominal 
viscera may be caused by infectious or brain diseases, ursemia or 
hysteria. 

Examination of Vomited Matter. — 1. Quantity. 
2. Macroscopical appearance. 3. Microscopical appear- 
ance. 4. Odor. 5. Reaction. 

1. Quantity. Large quantities in dilatation of the stom- 
ach. When vomiting is repeated the quantity expelled 
is less with each succeeding act. 

2. Macroscopical appearance. Watery, Mucus, Bloody, 
Purulent, Biliary and Fcecal. 



116 



MANUAL OF CLINICAL DIAGNOSIS. 



Watery vomit is represented by the vomitus matutinus {morning 
sickness of drunkards), consisting of swallowed saliva. The latter 
is recognized by the presence of ferro- cyanide of potash (blood red 
color on the addition of chloride of iron). 

Watery vomit may occur in nervous dyspepsia. If the vomit 
contains hydrochloric acid, it is the gastric juice and may indicate 
hyper-secretion of this fluid. In Asiatic cholera the vomit is 
alkaline and resembles rice water. 

Mucus in the vomit is observed in gastric catarrh. 

Bloody vomit (haematemesis). Examination of the nose, 
throat and lungs must first be made to exclude haemorrhage 
from these points, Bloody vomit occurs in ulcer and carcinoma 
of the stomach, cirrhosis of the liver, lesions of the stomach, 
haemorrhagic diathesis, etc., etc. In ulcer of the stomach the 
quantity of blood is large, in carcinoma it has a coffee ground 
appearance, because the haemorrhage is slow and is a long time 
in contact with the acid of the stomach. In haemorrhage from 
the stomach, blood may pass by the bowels {tarry stools). Vicari- 
ous haemorrhage occurs in delayed menstruation. 




Fig. 12. 

Fig. 12. Microscopical examination of the vomit, a. Muscular 
fibres b. Leucocytes, c c c' Pavement epithelium, c", Cylin- 
drical epithelium, d. Amyloid bodies altered by digestion, e. Fat 
globules, f . Barcinae ventriculi. g. Yeast fungi, h. Comma-bacilli. 
i. Various micro-organisms, j. Vegetable cells, k. Fat needles. 

Differential Diagnosis of Haemoptysis and Hsematemesis. — 
Haemoptysis. Blood is red, frothy, alkaline and salty to the taste, 



EXAMINATION OF INTESTINES. 117 

variable in amount, brought up by coughing, and there are usually 
physical signs of thoracic disease. 

Hcematemesis. Blood is dark, clotted and acid, large in amount, 
brought up by vomiting, and there are signs of abdominal disease. 

Purulent Vomit is rare and is observed in phlegmonous gastritis, 
and from an abscess of neighboring structures perforating the 
stomach. 

Biliary Vomit is frequent and of no special diagnostic impor- 
tance. Fluid gives reactions for bile. 

Fcecal Vomit usually indicates some mechanical obstruction of 
the intestines, and is a grave sign. 

3. Microscopical Examination. — The elements usually 
recognized may be seen in Fig. 12. 

4. Odor. Fatty acids give an acrid odor. In poisoning 
certain substances impart a characteristic odor. In urae- 
mia, ammoniacal odor (conversion of urea into carbonate 
of ammonia.) 

5. Reaction. Usually acid (hydrochloric or organic 
acids.) 

The reaction is alkaline in urcemia and when large quantities of 
blood are vomited. Vomit of esophageal origin (stricture) is 

alkaline. 



EXAMINATION OF THE INTESTINES. 

Inspection. — Peristaltic movements are only excep- 
tionally seen in health, when the abdominal walls are 
thin and flaccid. 

The movements are pathologically increased in stenosis 
of the intestines. According to the localization of increased 
peristaltic action the seat of the obstruction is determined. 

In intestinal obstruction there is obstinate constipation, pain and 
tenderness of abdomen, followed by violent peristaltic action and 
stercoraceous vomiting with collapse. 

The obstruction may be caused by; fcecal accumulation; history 
of constipation and obstruction comes on slowly ; peritoneal adhe- 
sions; history of preceding peritonitis; hernia, twisting of intestinal 
loops (volvulus) ; obstruction is snd len and occurs in perfect health. 
Site of obstruction. Lower part of colon ; disused prominence of 
the abdomen, faecal vomiting, no increase of indican in the urine 
and no decided decrease of urinary secretion ; duodenum or jejunum; 
abdomen is distended in the epigastric region while in other parts 
it is retracted ; collapse, anuria and indicanuria (see urine) ; ileum 



118 MANUAL OF CLINICAL DIAGNOSIS. 

and ccecum; distension is limited to the middle of the abdomen ; 
faecal vomiting, collapse and anuria. 

Diffused prominence of the abdomen may be caused by fat, infla- 
tion of the intestines with gas {meteorismus intestinalis) , air in the 
peritoneal cavity (meteorismus peritonei) the result of stomach or 
intestinal perforation and fluid in the peritoneal cavity (ascites). 
Retraction of the abdomen occurs in emaciation and when an active 
contraction of the intestines is present, as in basilar meningitis 
and lead colic. 

Palpation. — Pain on pressure may be diffused (in peri- 
tonitis and enteritis) or localized. 

Localized pain in the right inguinal region may be caused 
by intestinal tuberculosis, typhoid fever, typhlitis or 
affections of the vermiform appendix. The situation of the 
latter may be determined when the patient is lying down 
by drawing a line from the ant. sup. spine of the ilium 
to the umbilicus; about 2 inches from the spine of ilium 
in the course of this line is the vermiform appendix. 

Pain in the left inguinal region may be caused by 
inflammation of the descending colon (dysentery). 

Intestinal tumors may be confounded with fazcal impaction. 
Facal tumors are usually soft and may be moulded by the fingers; 
they disappear after brisk purgation. If the tumor involves the 
duodenum the symptoms are similar to cancer of the pylorus (gas- 
tral^ia, vomiting, dyspepsia, dilatation of stomach and retraction 
of abdomen). Contractions of the abdominal muscles must not 
be confounded with intestinal tumors. When the contractions of 
the abdominal muscles are irregular and associated with tympan- 
itic distension we have the so-called phantom tumors. These 
fictitious tumors disappear when an anaesthetic is used. 

Palpation of the Rectum is often necessary in the diagnosis of 
intestinal disease. The method of examination consists not only 
in the introduction of the finger, but, under the influence of an 
anaesthetic, of the whole hand. The hand, if small, may in many 
cases be introduced as far as the sigmoid flexure, and in this way 
the whole of the lower part of the abdomen may be explored. In 
order to test the calibre pi the large intestine, flexible sounds, 
supplemented by the injection of water, constitute important 
diagnostic measures. 

Percussion. — Over intestines containing gas, percus- 
sion yields a tympanitic sound, the height of which 
is influenced by the lumen of the intestines and the 
tension of its walls. If the intestines contain faeces 
in sufficient quantity, the sound while retaining the 
tympanitic quality, becomes duller. To determine the 



EXAMINATION OF PERITONEUM. 119 

relative position of the descending colon to other organs, 
it may be inflated with air by means of a sound connected 
with a Davidson syringe. 

Auscultation of the intestines maybe of importance in detecting 
the gurgling in the ileo-csecal region and friction fremitus in inflam- 
mation of the serous coat of the intestines. 



EXAMINATION OF THE PERITONEUM. 

Free fluid in the peritoneal cavity (Ascites') is distinctly 
a transudation, and -consequently non-inflammatory in 
origin. In inflammatory exudations of the peritoneum, 
the fluid is usually encysted and immovable. 

Physical signs of Ascites. 1. Distension of the Abdomen, in the 
recumbent position it is most manifest laterally. The fluid being 
movable it alters its position according to the position of the 
patient, thus producing, in different postures, distention of definite 
regions. 2. The skin, in consequence of increased tension, is 
smooth and glistening, and the cutaneous veins are dilated in 
high grades of ascites (collateral routes for the intra-abdominal 
veins which are compressed by the fluid), 3. Palpation practiced 
in the following manner will detect fluctuation: put one hand on 
the abdomen and with the fingers of the other hand practice 
percussion, when, if fluid is not under too great pressure, a distinct 
wave is felt by the hand. This symptom may be counterfeited by 
an excess of subcutaneous or omental fat. If the fluid is encysted 
fluctuation is indistinct. 4. Mensuration shows an increase in the 
abdominal circumference. This sign is only necessary when we 
desire to determine during treatment the increase or diminution 
in the amount of fluid present. 5. Percussion shows a horizontal 
boundary line of dullness which changes position according to 
the position of the patient. When the patient is in the recum- 
bent position a tympanitic sound is obtained on the anterior 
surface of the abdomen {the intestines floating on the surface of the 
fluid,) whereas, laterally and behind, a dull sound is obtained. In 
percussing in various positions remember that a certain time is 
necessary for the fluid to change its level. If the fluid is very 
large in amount or when the mesentery is too short, the intes- 
tines do not reach the surface of the fluid and there is dullness 
everywhere on percussion. When the fluid is small in amount, 
it first accumulates in the pelvis, in this case, put the patient on 
his side, so that the pelvis becomes higher and dullness will 
appear in the lateral region of the abdomen on the side in w r hich 
the patient lies. To detect the presence of a small quantity of 
fluid, i. e., less than "2 pints, the patient is placed in the knee- 
elbow position, when dullness will supersede the tympanitic sound 
in the umbilical region. 



120 



MANUAL OF CLINICAL DIAGNOSIS. 



DIFFERENTIAL DIAGNOSIS OF ASCITES 
AND CYSTS OF THE OVARY. 





ASCITES. 


OVARIAN CYSTS. 


Form of the abdomen. 


Anterior surface of ab- 
domen flat, sides dis- 
tended. 


Usually distension of the 
anterior surface & more 
marked on one side. 


Fluctuation. 


May be felt about the dull- 
ness. 


Confined strictly to the 
seat of dullness. 


Umbilicus. 


Disappears or is promi- 
nent. 


Pushed upwards. 


Percussion in the recum- 
bent position. 


Tympanitic sound on the 
anterior surface of abdo- 
men ; laterally and below 
dullness. Dullness also 
changes on position. 


The opposite. Dullness 
does not change accord- 
ing to patient's position. 


Examination per vagi- 
nam. 


Position of uterus usually 
not influenced, if so, is 
slightly lower than nor- 
mal. It is easily mova- 
ble. 


Uterus dislocated upwards 
or laterally. Mobility 
slight. 


Microscopical and chem- 
ical examination of 
the aspirated fluid. 


Pavement epithelium. 
♦Specific gravity of fluid 

L 1010-1015. Fluid clear & 
thin. Par albumen (Tare); 
Test: dilute fluid with 
water and introduce into 
same carbonic acid; a 
precipitate. Albumen 
small in quantity. 


Columnar epithelium. 
Specific gravity 1018- 
1024. Fluid cloudy and 
thick. Paralbumen fre- 
quently present. 



* Transudations and exudations. Serous exudations (inflammatory), have a 
greater specific gravity than transudations. When the specific gravity of a 
fluid exceeds 1018, it is of inflammatory origin. It is only a transudation when 
its specific gravity in ascites is less than 1012. The specific gravity is depen- 
dent upon the amount of albumen contained in these fluids and from the 
specific gravity, amount of albumen may be approximately determined after 
the formula of Reuss; 

E = % (s— -1000) — 2.8, in which E denotes amount per cent, of albumen 
sought and S the specific gravity; thus fluid of a specific gravity of 1018 con- 
tains 3.95 % of albumen. These rules hold good for serous exudations only. 
In taking the specific gravity the fluid must be the same as surrounding tem- 
perature; for every increase of 3° C. C5.4 °F.), the specific gravity is diminished 
by 1 degree. 



EXAMINATION OF THE FJECES. 121 

Causes of Ascites: Ascites without cedema in other parts of 
the body is usually caused by venous stasis in the portal system, a 
chronic affection of the peritoneum or tuberculous or carcinoma- 
tous peritonitis. In ascites due to disturbances in the portal 
circulation no albuminuria exists; as a rule, ascites co-existing 
with oedema of the extremities and cyanosis is usually caused by 
diseases of the heart or lungs. A chemical and microscopical 
examination of the urine will furnish evidence, if a nephritis is 
the cause of the ascites. 

Physical signs of free gas in the peritoneal cavity: dis- 
tension of the abdomen, dislocation of the thoracic viscera, 
tympanitic sound all over the abdomen, absence of 
hepatic and splenic dullness. 

Physical signs of gas and fluid in the peritoneal cavity: 
tympanitic sound over gas; and dullness over fluid. 
Change of position alters percussion sound, the gas 
always being above the fluid. If the patient is shaken, 
a splashing sound is heard. 

Subphrenic peritonitis {subphrenic abscess), is an encysted 
peritoneal exudation (pus) under the diaphragm, caused usually 
by ulcer of the stomach or affections of the intestines. If the 
abscess is punctured the fluid flows more rapidly during inspira- 
tion, whereas, if the fluid is confined to the pleural cavity, the 
flow during inspiration is less rapid because the pressure in the 
latter cavity sinks during this act. 



EXAMINATION OF THE FAECES. 

Faeces usually consist of the residue from the process of diges- 
tion mixed with the secretions of the intestines. 

Microscopical Examination. — In the microscopic examination 
of the stool, an inspected part is taken up with the forceps and 
deposited on a slide to which is added a drop or more of water. 
A thin watery solution of eosin is useful when staining is desirable. 

In -almost every stool we find the following (See Fig. 13) : 

1. Vegetable Food. Cellulose is very indigestible. It 
forms the frame of the vegetable form-elements and is 
recognized by its characteristic shape. Young vegetables 
are easily digested. 

2. Fat. Present even in normal stools. Pathologically 
it is increased when fat resorption in the intestines is 
prevented and is present in icterus and diseases of the 
pancreas. The fat is in the form of globules or needles 

3. Muscular Fibres. Present even in health. In creased 



122 



MANUAL OF CLINICAL DIAGNOSIS. 



in digestive disturbances. Recognized by transvere stri- 
ation of the fibres. 

4. Granular Detritus. Present in every stool and indi- 
cates thorough digestion. 

5. Blood Corpuscles. Undergo rapid destruction in the 
intestines. They are only recognized when the blood 
originates from the lower part of the large intestine and 
is rapidly discharged. Altered blood is recognized by 
Teichmann's test {see blood) conducted with the dried 
faeces. 




Fig. 13. 

Fig. 13. Microscopy of the stool. I. Vegetable food. 2. Mus- 
cular fibres. 3. Fat. 4. Crystal-needles of fat. 5. Granular 
detritus. 6. Blood corpuscles. 7. Mucus. 8. Triple phosphates. 



7. Mucus. Pathologically very much increased and 
appears microscopically as white globules imbedded in a 
gelatinous substance. 



EXAMINATION OF THE FMCES. 123 

8. Epithelium. In health only sparingly present. 
Appears as the cylindrical variety in acute enteritis with 
catarrh and in Asiatic cholera. 

9. Crystals. The triple phosphates are normally pres- 
ent; neutral calcium phosphate, cholesterin, leucin and 
tyrosin crystals may be found. 

10. Vegetable Parasites. Bacterium termo most frequent. 
Sarcinse ventriculi when they are present in the stomach. 
Yeast cells. 

11. Pathogenic Organisms. The bacilli of cholera, 
typhoid fever and tuberculosis. 

Cholera bacillus (comma bacillus). This is pathognomo- 
nic of Asiatic cholera. It resembles a comma and is about 
one-half to one-third the size of the tubercle bacillus, but 
plumper and thicker. It cannot with absolute certainty 
be recognized by microscopical examination so that the 
diagnosis must be based on the culture of the organism. 

Method of Beijwid. — The following is applicable for the physician. 
A two per cent, sterilized solution of peptone is rendered 
alkaline by the addition of a 0.5 per cent, solution of sodium 
chloride and bicarbonate of sodium. This solution is then inocu- 
lated with the suspicious faecal matter and allowed to remain in 
a thermostat for 24 hours. With the mixture thus obtained an 
addition of hydrochloric, sulphuric or oxalic acid, will yield a 
beautiful violet-red color if cholera bacilli are present. A similar 
reaction may be obtained with other bacilli, but it is less pro- 
nounced and requires alonger interval of time for development. 

Method of Schottelius. The suspected stool is mixed with an 
equal quantity of alkaline meat broth and placed in an open glass 
for 12 hours at a temperature of 30° -40° C. The bacilli rapidly 
develop on the surface, and are then examined under the micro- 
scope after staining. 

Bacilli of typhoid fever. They are constantly present 
in this disease in the affected portion of the intestine, 
mesenteric glands, liver, spleen, kidneys and blood, as well 
as in the stool. The bacilli are straight rounded at thpir 
ends and thick (thickness equals about i their length). 
The cover glasses are stained with methyl-blue in the 
usual way (see methods of demonstrating bacteria). Their 
presence microscopically in the faeces cannot with cer- 
tainty be determined owing to the large number of other 
micro-organisms present. 



124 



MANUAL OF CLINICAL DIAGNOSIS. 



Bacilli of tuberculosis. Present in the stool in intestinal 
tuberculosis. Their presence in the stool of phthisical 
persons may be due to swallowed sputum. For their 
demonstration (see sputum). 



MACROSCOPICAL EXAMINATION OF THE 

EfflCES. 



NORMAL CONDITIONS. 


ABNORMAL CONDITIONS. 


The reaction is alkaline. 


Acid reaction in infants, and in acid 
fermentation of the intestines. 


The normal color varies from a light 
to a dark brown and is colored by 
the bile. In an exclusive meat diet 
the color is brownish black. In a diet 
of starchy food, yellow brown; milk 
diet, yellow white. 


Absence of gall in the intestines (ic- 
terus) stool gray, greasy and clayey. 
Iron and bismuth make stool black; 
mercurial preparations, greenish 
brown; santonin and rhubarb, yel- 
low brown; logwood preparations, 
reddish brown. Blood from the 
intestines high up, tarry ; from the 
lower parts, red. 


The quantity in 24 hours in an healthy 
adult is from 100 - 200 grams, con- 
sisting of 75% water and 25% solids. 
It is dependent on the quantity and 
qualty of the food ingested. The 
consistency is firm or thick fluid. 


The quantity is increased in diar- 
rhoea, and after chronic constipa- 
tion, and administration of purga- 
tives. Consistency, thin fluid and 
•watery in diarrhoea. 


No departure from normal odor is 
diagnostic 


The odor is very intense when bile is 
prevented from reaching the intes- 
tines (Icterus). The odor is also 
intense in carcinomatous and syph- 
ilitic intestinal ulcerations. When 
urine is present, ammoniacal odor. 



The stools in typhoid fever have the appearance of cooked pea 
soup; the smell is offensive and characteristic. In dysentery the 
stools contain bloody mucus ; in cholera, they resemble rice water. 
In pancreatic disease, the stools are colorless and contain much fat 
either free or as an oily scum forming tallow-like masses on cool- 
ing. In increased peristaltic action of the intestines, the stool 
may consist of undigested food (lientery). 

Mucous and membranous casts may be present in membranous 
colitis. Portions of bowel may be found in intussusception and 



EXAMINATION OF THE LIVER. 125 

exfoliated mucous membrane in dysentery and ulcerative colitis. 
The chemical examination of the faeces is without special clinical 
value. 



EXAMINATION OF THE LIVER. 

Methods. Inspection, Palpation, Percussion, Ausculta- 
tion. 

Anatomy of the Liver.—It is covered by the peritoneum and 
situated in the right hypochondriac region extending across the 
epigastrium into the left hypochondrium. It is the largest gland 
in the body, weighing from 3 to 4 pounds. It measures, 
in its transverse diameter, from 10 to 12 inches ; from 6 
to 7 inches in its antero-posterior diameter ; and is about 
3 inches thick at its thickest part. About X of the liver 
is situated to the right and % to the left of the median 
line. The upper part of the liver on the right side is 
covered by lung and rises under the diaphragm to the 4th 
intercostal space. The lower border is situated in the scapular 
and middle axillary lines at the eleventh rib; in the mammary line 
at the curvature of the ribs and in the median line between the 
xiphoid process and the umbilicus ; it then takes a curved direc- 
tion, attaining a point near the apex beat, between the left mam- 
mary and parasternal lines. 

The gall bladder lies between the right mammary line and the 
outer border of the rectus abdominis muscle, directly under the 
curvature of the ribs. 

Inspection. — The region of the liver in health shows 
no prominence unless in children who possess a relatively 
large liver, the latter being in a condition of physiologi- 
cal fatty infiltration. When the liver is enlarged and the 
ribs elastic (in children and young women) the hepatic 
region becomes prominent. 

The intercostal spaces are preserved in hepatic enlargement and 
this fact serves as a means of diagnosis from pleural exudations 
of the right side, which cause a disappearance of these spaces. The 
lower border of the liver is rarely r-een in enlargement of this organ, 
but the abdomen is often marked by a furrow which represents in 
many cases the lower border of the enlarged vise us. The liver 
descends during inspiration and so does the spleen but not to the 
same extent as the former. This respiratory dislocation serves as 
a clue to diagnosis in differentiating enlargement of the liver or 
spleen from tumors of the kidneys, stomach, pancreas, omentum 
and intestines, which undergo no dislocation during respiration 
unless adhesions exist between them and the liver and spleen, 
in which case the movements of these organs are communicated. 



126 MANUAL OF CLINICAL DIAGNOSIS. 

The lower liver border may be discernible irrespective of enlargement 
of this organ when it is dislocated by pleural exudations, tumors, 
deformities of the thorax and emphysema, The liver is also 
dislocated (in women who have borne many children) when the 
suspensory ligament is relaxed leading to the condition known as 
wandering liver. An enlarged gall bladder may likewise cause 
a prominence of the hepatic region. Pulsations in hepatic region 
may be transmitted from the underlying aorta in which case they 
are usually confined to the left lobe of the liver and the motion 
is an up and down one. True pulsation of the liver is an important 
symptom of tricuspid insufficiency. 

Palpation. — This is the most important and certain 
method of examination. To accomplish palpation prop- 
erly observe the following : 

Place patient on his back and relax abdominal muscles by 
bending the legs and introducing a cushion under the shoulders. 
Palpate with warm hands and direct patient to open the mouth 
wide and breathe naturally. The palpation of the lower border 
is facilitated by asking the patient to take a deep breath. Fluid 
in the peritoneal cavity interferes with palpation, and before 
this can be accomplished the fluid must be aspirated or the 
patient put in the knee-elbow position. 

In the healthy adult the surface and lower border of the liver 
cannot be felt. In children, however, the contrary is the case. 
In healthy women the lower liver border may occasionally be 
felt. This constitutes the liver of tight lacing (schniirleber) and 
usually involves the right lobe, which may be separated from the 
rest of the liver by a horizontal furrow. 

In palpation of the diseased liver the following are 
determined : Pain on pressure, size, form, consistency 
and surface of the liver. These conditions will receive 
consideration in the appended table of liver diseases. 

The gall bladder may be felt in cases of extreme 
emaciation. When distended with bile (hydrops vesicae 
fellse) and gall stones it may be palpated. 

The latter condition gives the same impression on palpation as 
does a bag filled with stones. When distension of the gall blad- 
der is produced by the accumulation of bile, it may be diminished 
in size by compression or faradization of the region occupied by 
the gall bladder, the effect secured being the emptying of its 
contents into the duodenum. 

Percussion. — Two forms of liver dullness are differ- 
entiated; the superficial or absolute and the deep or relative. 
The superficial or absolute liver dullness represents the 
liver entirely uncovered by lung tissue. The percussion 



EXAMINATION OF THE LIVER. 127 

sound over this area is flat and light percussion must 
invariably be employed. The upper border of this dull- 
ness corresponds with the lower border of the lung and is 
as follows : 

In the right sternal line, at the lower border of the 5th costal 
cartilage. 

In the right parasternal line, at the upper border of the 6th 
costal cartilage. 

In the right mammary line, at the lower border of the 6th rib. 

In the right axillary line, at the upper border of the 7th rib. 

In the right scapular line, at the 9th rib. 

Alongside of the vertebral column, at the 11th rib. 

Lower border of the absolute dullness : 

In the median line, between the xiphoid process and umbilicus. 

In the right mammary line, at the curvature of the ribs. 

In the axillary line, between the 10th and 11th ribs. Along side 
the vertebral column it cannot be determined ow r ing to the situa- 
tion of the kidney. 

Deep or Relative Liver Dullness — This represents not 
only the liver uncovered but also partially covered by 
lung tissue. It does not reproduce the actual size, 
because it is impossible for the percussion blow to reach 
the upper part of the liver which is covered by lung tissue 
of too great thickness. 

Strong percussion is necessary in obtaining this form of dullness, 
the upper border of which runs parallel with the superficial dull- 
ness, although about 1)4 inches higher ; whereas the lower bolder 
corresponds with the low r er border of absolute dullness. The 
latter form of dullness is usually relied on. 

Area of Liver Dullness in Respiration. During deep inspiration 
the liver dullness is diminished in area owing to the descent of 
the lung border, about 1*4 inches. When the patient lies on the 
left side the dullness of the liver disappears, because the right 
lung almost completely fills the complemental space. 

In disease the liver dullness may be absent, increased, 
diminished or dislocated. 

IAver dullness is absent in wandering liver, gas in the peritoneal 
cavity and in transposition of the viscera. 

Increased liver dullness does not always correspond with an 
increase in the size of the organ, inasmuch as the dullness is 
influenced by the position of the lower lung border. When the 
low T er lung border is in its normal situation and the liver border 
is low r er than normal, sufficient evidence is furnished of an enlarge- 
ment of the liver. In such a case the left lobe of the liver {it 
extends normally from 7 to 8 cm. to the left of the median line) 
may extend to the anterior border of the spleen. 



EXAMINATION OF THE SPLEEN. 129 

Pleural exudations, tumors of the lung and pleura and consoli- 
dation of the luntf on the right side render percussion of the upper 
border of the liver impossible, as one dullness cannot be separated 
from another. An apparent increase of liver dullness can also 
be produced by solid matter in the colon and stomach. 

Diminished liver dullness does not always correspond with a 
decrease in the size of the organ. An apparent diminution in the 
area of dullness may occur; when the transverse colon is pushed 
between the liver surface and the chest wall, in emphysema of 
the lung and in distension of the stomach and intestines. 

Dislocation of the liver dullness occurs when the liver is dislo- 
cated upwards in inflation of the intestines, ascites, tumors of 
the abdominal organs and contraction of the right lung. A 
dislocation downwards occurs in pulmonary emphysema, pleural 
exudations, mediastinal tumors, etc. 

Auscultation of the liver is usually devoid of positive results. 
Friction murmurs in perihepatitis and arterial murmurs either 
transmitted from the heart or occurring spontaneously in the 
Uver, may at times be heard. 



EXAMINATION OF PANCREAS, OMENTUM 
AND RETROPERITONEAL GLANDS. 

Pancreas. Tumors of this organ may occasionally be palpated 
fn the epigastrium, directly under the lower border of the liver. 

Omentum. This is only palpable immediately about the 
umbilicus in rare instances, when thickened by inflammation 
or is the seat of new growths. 

Retroperitoneal Glands. They may^ be secondarily involved in 
carcinoma. They are deeply seated in the abdomen on a level 
with the umbilicus. 



EXAMINATION OF THE SPLEEN. 

Methods. Inspection, Palpation, Percussion, Auscul- 
tation. 

Anatomy of the Spleen. — The spleen is a long, nearly oval 
shaped organ, lying in the left hypochondrium, between the 9th 
and 11th ribs. Its anterior end does rot normally reach, or at 
any rate, go beyond a line drawn from the tip of the 11th rib to 
the left sterno-clavicular articulation (costo- articular line). Its 
posterior border usually terminates at a distance of 1 inch from 
the 10th dorsal vertebra. It has 3 surfaces. The outer convex 
surface is directed towards the under surf ace of the diaphragm, 
the inner concave surface is directed towards the fundus of the 
etomach, while a small part of its under surface covers the upper 

M. 0, ». 9 



130 MANUAL OF CLINICAL DIAGNOSIS. 

part of the left kidney. The weight of the spleen in the male is 
about 7 ounces; female, 6 ounces. It is about 5 inches long, 3j^ 
inches broad, and li£ inches thick. In old age the organ deci eases 
in weight. 

Inspection. — The splenic region shows no departure from the 
normal unless the spleen is considerably enlarged, in which case, 
a prominence of the left hypochondrium and the adjacent 
abdominal region may be noted. When the spleen enlarges it 
grows downwards from the left hypochondrium into the umbilical 
and hypogastric regions, and may, in excessive enlargement, 
occupy a large portion of the peritoneal cavity. 

An enlarged liver grows downwards from the right side; an 
enlarged uterus grow 7 s upwards from the hypogastric region, while 
an enlarged ovary grows upwards from either inguinal region. 

Splenic tumors are nearly always recognized by their dislocation 
on change of position and during respiration. 

Palpation. — This is the most important of all the 
methods of examination, and we are less likely to err in 
palpation than percussion. A normal spleen is rarely 
felt. 

. In palpation put patient in the right diagonal position ; patient 
lies on the right shoulder with the left arm raised tow T ard the 
head and midway betw r een the dorsal decubitus and side position. 
This position is the most favorable for palpation of the spleen. The 
ringers of the right hand are now pressed dovvnwards and 
upwards into the space between the 10th and the free end of 
the 11th ribs, and the patient is told at the same time to take a 
deep breath, when, if the organ is enlarged, it is felt as a rounded 
body, receding from the fingers during expiration. If the organ 
is soft only an increased resistance is felt. The spleen may be 
palpated when it is dislocated and not necessarily enlarged. 

The following conditions are observed in palpation: 
form, size, consistency, pain, mobility and the condition 
of the surface of the spleen. 

Form of the Spleen. Tumors of the spleen usually 
reproduce on a larger scale the original form of this 
organ. The anterior margin of the normal organ presents 
from one to four notches which are pronounced in enlarge- 
ments of this organ. Palpation of these notches is of 
great importance in differential diagnosis. 

Size of the Spleen. This varies according to the causes 
concerned in the enlargement. The largest spleen is 
usually of leucsemic origin. 

Consistency of the Spleen. As a rule, the larger the 



EXAMINATION OF THE SPLEEN. 131 

spleen the harder the consistency. Acute are usually 
of softer consistency than chronic splenic enlargements. 

Pain. Usually absent in splenic enlargements unless 
the peritoneum is secondarily involved. 

Mobility of the Spleen. This is effected by pressure 
with the hand, change of position and during respiration. 

Condition of the Splenic Surface. It may be nodular 
and irregular; in thickening of the capsule (rare), 
carcinoma, sarcoma, echinococci, gummata, cysts, 
abscesses and varicose dilatation of the splenic veins. 

Mobility of the Spleen during inspiration may be absent when 
the enlarged organ presses on the diaphragm arid interferes with 
its contraction. In women the spleen may leave its normal 
situation (wandering spleen). It is recognized by its form, by the 
notches on its anterior margin, by excessive mobility, absence of 
dullness in the splenic region, and by its relationto the colon. 
Wandering and enlarged spleens lie in front of the colon a 
relationship which can be recognized by inflation of the latter. 
Palpation of the spleen may give rise to a cough (spleen cough) 
and is due to mechanical irritation of the peripheral branches of 
the pneumo-gastric nerve. 

Percussion. — A large part of the spleen is covered by 
lung which interferes with percussion of the entire organ. 
Only that portion can be percussed which is not covered 
by lung. 

The Area of Percussion Dullness is bounded above by the 
left lower lung border, which in the right diagonal position is at 
the 9th rib in the middle axillary line ; the lower border runs 
parallel with the 11th rib, and just before reaching the left scap- 
ular line it joins the lateral border of the left kidney. The 
breadth of the splenic dullness in the middle axillary line is from 
2 to 2}£ inches. The normal splenic dullness does not reach 
forward beyond the costo- articular line. The percussion blow 
must be very light. The splenic dullness is separated from the 
resonance oi the lung above, and on the sides, from a tympanitic 
sound. The figure of dullness will alter according to the positi. n 
of the patient, hence the necessity of always percussing in 
one position, the right diagonal being preferred. On inspiration, 
owing to the descent of the lower border of the left lung, the 
splenic dullness is diminished. 

In health the figure of splenic dullness is influenced by so many 
conditions that percussion ceases to be an exact method of 
examination. The position of the left lower lung border will 
either increase or diminish the dullness, and a fatty omentum 
or accumulations in the stomach and colon, exert a decided 



132 MANUAL OF CLINICAL DIAGNOSIS. 

influence on the percussion area of the spleen. If an apparent 
enlargement of the spleen is found on percussion and the organ is not 
palpable , always question the correctness of the percussion. The 
excellent advice of Piorry should be remembered, viz. : That the 
certainty of splenic percussion increases after free purgation. 

The splenic-dullness may be increased, diminished or 
absent. 

Increased splenic dullness occurs in certain acute infec- 
tious diseases (typhoid, malaria, pyaemia, etc.), obstruction 
of the portal circulation, amyloid degeneration, leucaemia 
and new growths in the organ. 

Enlargement is assumed to exist when the percussion al breadth 
is increased ; when the dullness goes beyond the costo-articular 
line (in only T V of the cases does the normal eplenic dullness 
go beyond this line), and when the sense of resistance on 
percussion is increased. An apparent enlargement is observed 
in pleural exudations of the left side, and in infiltration of the 
lower portion of the left lung. 

Diminished splenic dullness occurs in pulmonary emphys- 
ema owing to encroachment of the dilated lung on the 
area of splenic dullness, and when the intestines are 
distended with gas. 

The splenic dullness is absent when the spleen is absent 
(rare), in wandering spleen, and when air is present in 
the peritoneal cavity ; the air occupies the region between 
the surface of the spleen and the thoracic wall thus substi- 
tuting a tympanitic for a dull sound. 

Auscultation of the spleen. When the capsule of the 
spleen is roughened friction sounds may be heard. 
Arterial murmurs have been heard in intermittent fever. 



CHAPTER XI. 

EXAMINATION OP THE GENITO-TTRIN- 
ARY ORGANS. 

EXAMINATION OF THE KIDNEYS. 

Anatomy. The kidneys lie on both sides of the vertebral col- 
umn from the level of the 12th dorsal to the 3d lumbar vertebra. 
The right is about % of an inch lower than the left kidney. The 
kidney is about 4 inches long, 2 inches wide, 1 inch thick, and 
weighs in the male about 5J^, and in the female 4J^ ounces. 
Tiie right kidney encroaches above on the liver, the left kid- 
ney on the spleen. The outer border of the kidneys is about 
4 inches external to the spinous processes of the vertebne, and 
corresponds with the outer border of the sacro-spinalis muscle. 
The anterior surfaces of the kidneys are covered by the parietal 
layer of the peritoneum. The ascending colon lies in front of 
the right kidney, the descending colon in front of the left. 

Physiology. In the kidneys the water is filtered off through the 
glomeruli with certain inorganic salts, and is dependent entirely 
upon blood pre sure. The secretion proper takes place in the 
epithelium lining the tubules, and is practically independent of 
blood pressure. 

Examination of the Normal Kidneys. The usual phys- 
ical signs are without special value, even under the 
most favorable conditions (flaccid and thin abdom- 
inal walls, atrophy of the sacro-spinalis and quadratus 
lumborum muscles). 

Inspection. When the kidney is excessively enlarged, 
a distension of the region occupied by it may be noted. 

Palpation. This is the most important local method 
of examination. 

In palpating the kidney the patient is placed on his back with 
the legs flexed on the abdomen and bimanual palpation is made 
with one hand on the lumbar region, the other on the abdomen. 
Pain on pressure is occasionally experienced in acute nephritis, 

(133) 



134 MANUAL OF CLINICAL DIAGNOSIS. 

renal tumors, inflammatory hydronephrosis and perinephritis. 
Large tumors of the kidney (sarcoma, carcinoma) may be felt as 
irregular nodules; whereas in hydronephrosis the kidney surface 
is smooth, tense and fluctuation may be present. Echinococci of 
the kidney may be felt as elastic cysts, eliciting a peculiar vibra- 
tion, similar to the sensation perceived on striking a mass of 
J e Uy {fremitus of hydatids). Tumors of the kidneys exhibit no 
movement during inspiration or by pressure, unless a wandering 
kidney exists. 

Wandering or floating kidney is comparatively frequent in 
women who have borne children. The right kidney is the one 
usually involved (greater length of the renal vessels and the 
looser attachment of the right kidney). 

An important point to remember in differential diagnosis is, 
that the colon always lies in front of the kidney, and inflation of 
the colon from the rectum with gas or air is often necessary to 
establish this relation. 

Percussion. — Only the outer convex and lower 
border of the kidney can be percussed from the tympan- 
itic sound of the neighboring intestines. Even this is 
only possible when the latter are empty. 

Examination of the Ureters and the Bladder — Ureters. — They 
are frequently palpated with the hand introduced into the 
rectum. In women they may be felt by vaginal examination. 
The endoscope has been used to render manifest the opening of the 
ureters into the bladder, and to determine their length (normal, 16 
to 18 inches) by the introduction of sounds. The ureters are 
thickened and painful on pressure in cysto-pyelitis and tuberculosis 
of the urinary apparatus. They may be dilated in pyelitis calcu- 
losa. 

Bladder. — This may be palpated through the abdominal wall 
when it is distended with urine. When abnormally distended it 
may almost reach the ensiform cartilage. Pressure on the distended 
bladder occasions a desire to urinate. Percussion is serviceable 
in marking out the distended viscus. The internal examination 
of the bladder maybe made by digital examination per rectum. 
Auscultation practiced with the sound moved about in the bladder 
is valuable when calculi are present. A filled bladder has been 
confounded with tumors of the pelvic viscera; the use of tiie 
catheter will solve the difficulty. The improved apparatus of 
Leiter and Nitze, with which the interior of the bladder is illum- 
inated by means of the electric light is a valuable aid to diagnosis 
in the hands of experts. 



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(136) 



DISEASES OF THE BLADDER. 137 

DIAGNOSIS OP DISEASES OP THE 
BLADDER. 

Cystitis. — In the acute form of this affection the 
bladder region is painful ; the urine is diminished, 
cloudy and acid in reaction. The sediment is abundant, 
and contains leucocytes, red blood corpuscles and bladder 
epithelium. In chronic cystitis, the urine is cloudy, 
dirty brown in color, alkaline (ammoniacal fermentation) 
and contains a sediment of pus. 

Cystitis Calculosa (bladder calculi). — Usual signs 
of cystitis. Hematuria is a frequent complication. 
Crystalline deposits are present in the urine, or they are 
expelled as gravel. Pain is often intense, and radiates 
towards the urethra and glans penis. The pain is usually 
increased by active movements of the body. Strangury. 
The diagnosis is only positive when a calculus is detected 
by means of the sound. 

Cancer of the Bladder. — Hematuria, and pain in 
the bladder region uninfluenced by movement. Cancerous 
particles may be expelled with the urine. Enlargement 
of the inguinal glands and cachexia. The diagnosis is 
positive when a tumor can be palpated from the rectum 
or vagina, or by means of a catheter. 

Nervous Disturbances. — In paralysis of the longi- 
tudinally arranged muscular fibres of the bladder 
(Detrusor vesica) there is retention of the urine (Ischuria 
paralytica) ; the retention continues until the pressure of 
the accumulated fluid overcomes the resistance of the 
circularly arranged muscular fibres of the bladder 
(Sphincter vesicae) and the urine is expelled drop by drop 
(Incontinentia urinse or Enuresis paralytica). In spasm 
of the bladder (cystospasmus) involving the Sphincter 
muscle the urine is passed in small quantities (Dysuria 
spastica) or when the spasm is pronounced, no urine is 
expelled (Ischuria spastica). Spasm of the Detrusor is 
characterized by a sudden and frequent desire to urinate. 



138 MANUAL OF CLINICAL DIAGNOSIS. 



URINARY CALCULI. 

Calculi are solid masses formed by deposition of inorganic or 
organic constituents of the urine. They may occur of any size 
from mere granules (gravel) to masses as large as the fist (calculi). 
Calculi are usually composed of a nucleus consisting most fre- 
quently of oxalate of lime or organic matters (mucus, blood, 
parasites or foreign bodies). 

Calculi in Acid Urine. — Uric acid. Hard and heavy, of a red- 
dish yellow color. Moisten some of the powder with a drop of 
nitric acid and slowly evaporate in a dish. If uric acid is present, 
an orange-red mark is left which turns purple on being moistened 
with ammonia (murexide test). Oxalate of Lime {mulberry calculi) 
occur next in frequency to uric acid, forming about £ of all calculi. 
Very common in children, and may be passed as hemp seed-like 
bodies. They are hard, irregular and dark brown or purple in 
color. The powdered calculus is not dissolved by acetic acid 
but dissolves without effervescence in mineral acids. 

Cystine Calculi (very rare) ; yellowish-white color with a granular, 
glistening crystalline surface. Fragments dissolve in ammonia 
and separate on evaporation as regular hexagonal crystals of 
cystine. Xanthine (very rare) ; yellow brown color, and glistens 
like wax on friction. 

Calculi found in Alkaline Urine. —-l/&red phosphates (fusible 
calculi) ; consist of the mixed calcium, ammonium and mag- 
nesium phosphates. These substances are usually constituents 
of other calculi which have remained in the bladder until the 
urine has become alkaline and ammoniacal. Under these 
circumstances they form a very friable crust over the calculi. 
They are soluble in acids and fuse under the blow-pipe into a 
glassy slag. 

Phosphate of Lime (rare) ; white and chalky, break with an 
earthy fracture and appear regularly stratified. 

Carbonate of Lime (rare) ; small rounded bodies and generally 
very hard. Dissolved with effervescence in hydrochloric acid. 

The Uro-stealith calculus is probably composed of some fatty 
material. Blood calculi only occur in renal hematuria. 

Analysis of Urinary Calculi. — The calculus is powdered or a 
portion of each layer, or any layer scraped off is powdered and 
burnt on a piece of platinum foil over a Bunsen flame or spirit 
lamp. The specimen may : 1. Carbonize and disappear. 2. May 
partly carbonize and leave a residue. 3. May undergo little or no 
blackening. 

1. If the specimen burns and leaves no residue the calculus 
consists of uric acid urate of ammonia, cystine, xanthine or fibrin. 
A fresh portion is digested with a strong solution of ammonia 



PATHOLOGICAL CONCREMENTS. 139 

and filtered; the filtrate is evaporated depositing crystals of 
cystine (recognized microscopically). The insoluble portion is 
dissolved in nitric acid and the solution evaporated; a yellow 
residue which turns red on adding caustic potash in the cold, and 
violet when heated, indicates xanthine ; a pink residue, giving a 
purple color with ammonia, indicates uric acid, 

2. The specimen carbonizes and burns, leaving a residue. The 
calculus contains organic and inorganic constituents. To deter- 
mine these, boil in water another portion of the powdered calculus 
filter while hot; a deposit on cooling indicates urates or uric acid. 
The insoluble portion in boiling water should be treated with 
acetic acid and filtered. Filtrate may be tested for earthy phos- 
phates, whilst the residue dissolved in hydrochloric acid, and the 
solution super-saturated with ammonia, will give a crystalline 
deposit if oxalate of lime is present. 



PATHOLOGICAL CONCREMENTS. 

Facal calculi (enteroliths), consist of organic substances and 
inorganic salts (phosphate of calcium, ammonio-phosphate of 
magnesium, etc). They should be dissolved in muriatic acid and 
examined in the usual way. 

Salivary calculi generally consist of carbonate of lime. 

Rhinolilhs are calcareous concretions formed around some im- 
pacted foreign body in the nasal cavity. They may be due to the 
inspissation of nasal secreticns. 

Gall Stones. — They consist of cholesterine or bile pigment or 
rarely of carbonate or phosphate of lime. Biliary concretions are 
usually deposited around a iricleus of inspissated mucus. Choles- 
terine calculi are smooth, light-colored faceted when multiple and 
quite hard. Their crushed surface shows radiating lines of 
fracture. Cholesterine is detected by dissolving a portion of 
the powdered calculus in hot alcohol and filtering; after cooling 
it crystallizes in slender plates. If cholesterine is dissolved in 
chloroform and sulphuric acid added, a cherry-red color is formed. 
Gall-stones consisting of bile pigment are almost black in color, 
small and irregular in shape, very friable, and occur in large 
numbers. Test (or bilirubin with Gmelin's reaction. 



THE URINE. 

Examination of the urine is essential in learning the condition 
of the kidneys and bladder; and determining qualitatively and 
quantitatively those products [urea, etc.) which originate in the 
disintegration of albumen. The force of the heart's action and 
certain affections of other organs may also be determined. The 



140 MANUAL OF CLINICAL DIAGNOSIS. 

products of the decomposition of fat and carbo-hydrates pass 
out of the body as carbonic acid and water by the lungs ; whereas 
the products of albumen pass out in the urine. 

Normal Urine. — It is a transparent amber-yellow 
colored fluid ; consistency of water; saline taste; aromatic 
odor; acid reaction; specific gravity, 1015 to 1025, at a 
temperature of 60° F. The quantity excreted in 24 
hours in health, by men, is about 1500 — 2000 ccm. (40 — 
60 ounces); and by women 1000—1500 ccm. (30—40 
ounces). 

Reaction. — Normal urine is acid, due to the acid 
phosphates of sodium (Na H 2 P0 4 ). The reaction is 
determined by blue and red litmus paper (tumeric paper 
is of little value). Blue litmus paper will be turned to a 
red color, if urine is acid; if alkaline, it will turn red 
litmus paper blue. Amphoteric reaction is present when 
red litmus paper is turned blue and blue litmus paper 
red. To distinguish between fixed alkali and that due to 
the presence of ammonia (decomposed urine), the litmus 
paper after being dipped in the liquid is allowed to dry ; 
the blue color disappears in ammoniacal urine, but 
remains if the alkalinity is due to a fixed alkali. 

The degree of acidity of the urine is determined by acidimetry, 
i. c., titration with a decinormal solution of potassium hydrate, 
expressing result in the corresponding amount of oxalic acid. 

Alkaline Reaction from fixed Alkalies. — This occurs after a 
vegetable diet, the use of caustic alkalies, alkaline carbonates or 
alkaline salts of the vegetable acids, by mixture with blood or 
pus, etc. During digestion urine may become alkaline. 

Alkaline Reaction from a Volatile Alkali. — This results from 
the presence of bacteria decomposing urea into ammonium car- 
bonate; 

CO (N H 2 ) 2 + 2 H 2 O - (NH,) 2 C0 3 

urea water ammonium carbonate 

This alkaline fermentation may occur within or without the 
body. 

The alkalinity from fixed alkalies causes precipitation of the 
earthy phosphates while ammoniacal alkalescence causes the 
formation of triple-phosphate. 

An acid reaction in the presence of pus is strong evidence of its 
renal origin. Chronic cystitis is usually associated with an alkaline 
urine. 



THE URINE. 141 

Color. — This may vary in health owing to concentra- 
tion or dilution, or in disease owing to the presence of 
pathological pigments. 

The urine of diabetes, hysteria, anaemia, convulsions 
and contracted kidney is usually pale ; in fever it is 
high-colored owing to a diminished quantity of water. 

The normal urinary coloring bodies are indican and 
urobilin. Indican (uroxanthine) is increased (indicanuria) 
in obstruction of the intestines (absorption of indol of the 
faeces), peritonitis, chronic constipation, and occasionally 
in health. 

Test for indican: Mix with the urine an equal part of hydro- 
chloric acid and 1 or 2 drops of a concentrated solution of calcium 
chloride diluted one half with water. The chloride of calcium 
solution is added drop by drop until a blue color appears. A few 
ccm. of chloroform are then added and the whole shaken, which 
brings out the indigo. 

Urobilin colors the urine red or brownish-red. Present 
in health in small quantities. It is increased in febrile 
disease and during the resorption of large blood extrava- 
sations. 

Tests for urobilin : Spectroscope. An absorption line between 
the green and the blue of the spectrum. 

Chemical : Add to the urine 2 — 5 drops of a 10% solution of 
chloride of zinc and enough ammonia afterwards to re-dissolve 
the precipitated oxide of zinc ; a green fluorescence is observed if 
the test-tube is held against a dark background. 

Blood-coloring matter. The urine is either bright red 
with a greenish iridescence owing to the presence of 
oxy-haemoglobin or a dark brownish-red, owing to the 
presence of meta-hsemoglobin. 

Blood-coloring matter occurs in: 1. Hxmaturia (color- 
ing matter present in combination with blood corpuscles). 
2. Hemoglobinuria (coloring matter is in solution without 
blood corpuscles in sediment). Hsemoglobinuria results 
from hsemoglobinsemia which is caused by poisoning 
(chlorate of potash, mineral acids, etc.), infectious 
diseases, burns, etc. 

Bile coloring matter. The urine is of a beer-brown color 
and has a yellow foam on shaking. 
Medicinal agents. The urine is brown or black after 



142 MANUAL OF CLINICAL DIAGNOSIS. 

the ingestion of carbolic acid and gallic acid; yellow after 
santonin and chrysophanic acid. 

A dark brown or blackish color of the urine occurs in 
melanotic tumors, owing to the elimination of uromelanin, 
a black coloring body similar to the choroidal pigment. 

Quantity. — 1. Increased (polyuria) in hydrsemia. 
2. Contracted kidney (caused by the accompanying 
hypertrophy of the left ventricle increasing blood 
pressure). 3. During the resorption of exudations and 
transudations. 4. Diabetes insipidus and mellitus. 5. 
After great thirst (polydipsia). 

Transitory polyuria is observed in nervous individuals after 
mental excitement, and after the use of coffee, beer, wine and 
diuretics. 

The quantity is decreased : 1. From loss of water 
(perspiration, diarrhoea, formation of exudations and 
transudations). 2. Fever. 3. Diminished blood pressure 
(valvular heart diseases). 4. Acute and chronic paren- 
chymatous nephritis. 5. Obstructions to the excretion 
of urine (strictures of the urethra and ureters). 

Transparency. — Normal urine is clear. An opacity 
occurring in urine of an acid reaction may be due to 
uric acid salts (urine clears on heating) or to certain 
organic constituents recognizable with the microscope. 
An opacity in alkaline urine is usually due to the phos- 
phates or more rarely to calcium oxalate or organic 
constituents. The urine is rendered opaque in chyluria 
owing to the presence of emulsified fat (galacturia) or to 
large fat drops on the surface of the vr'me (lipuria). 

Specific Gravity. — This is ascertained with the 
urinometer (ardometer) or for greater accuracy by a 
specific gravity bottle (picnomeler). In taking the specific 
gravity, the urine of 24 hours should be collected and a 
sample taken from it. 

The specific gravity may vary from 1002 (contracted 
kidney and diabetes insipidus) to over 1060 (diabetes 
mellitus and fever). As a rule, a low specific gravity 
indicates a diminished and a high specific gravity, an 
increased excretion of urea. 



CONSTITUENTS OF NORMAL URINE.. 143 

Estimation of Total Solids. — This can be approximately deter- 
mined, if the last two figures of the specific gravity be multiplied 
by the co-efficient 2.33 (Hxser) or by 2 {Trapp) or 2.2 (Losbisch); 
the result, is the amount in grams in 1000 ccm. of urine. If 
1200 ccm. be the amount of urine and the specific gravity 1022, 
then 

22x2.33=51.26 grams in 1000 ccm. 

• -.o™ 51.26x1200 C1 K1 
or in 1200 ccm. = — — = 61.51 grams. 

Odor. — It is ammoniacal in decomposition of the 
urine. In diabetes the urine has a fruity odor. Spirits of 
turpentine yield an odor like violets; copaiba, cubebs, 
and oil of sandalwood, an aromatic odor. Urine contain- 
ing cystine smells at first like sweetbriar, but afterwards 
becomes very offensive. The odor of the urine after 
taking garlic and asparagus is well known. The urine 
has a putrid odor when it contains decomposing blood or 
pus. 

CONSTITUENTS OF NORMAL URINE. 

Urea [CO(NH 2 ) 2 ]. — The daily amount excreted by 
healthy persons is between 20-40 grams (300-600 grains). 
Urea is increased in an albuminous diet, and in an 
increased loss of the albumen of the body (diabetes mel- 
litus, phosphorus poisoning, fever, etc.) It is decreased 
in inanition, in a deficient nitrogenous diet, in acute yel- 
low atrophy of the liver and in diseases of the kidney. 

Urea is a soluble organic salt and represents the chief ulti- 
mate product of nitrogenous waste ; it constitutes about 3 per 
cent, by weight of the urine. It crystallizes in silky, four-sided 
prisms, with oblique ends or in delicate white needles. 

Chemical Test (biuret reaction). — Heat a specimen of urea until 
it ceases to give off ammoniacal vapors. If potassium hydrate and 
a drop of cupric sulphate solution are added to the residue, the 
color is changed to a reddish violet. 

Microscopical Test. — This is important in detecting urea in 
sputum, vomit, transudations, etc., in the diagnosis of uraemic 
conditions. Evaporate fluid to the consistency of syrup, extract 
with alcohol and filter. The tiltrate is then evaporated, the residue 
dissolved in a little water and concentrated nitric acid added to it. 
After a little while, hexagonal crystals of nitrate of urea appear. 

The quantitative determination of urea may be accomplished 
by the balance, precipitation by means of certain standard liquids 



U4 MANUAL OF CLINICAL DIAGNOSIS. 

and volumetric analysis. The last is the only ready and rapid 
method suitable for the physician. It is based upon the fact that 
urea decomposes into nitrogen and carbonic acid in the presence 
of certain bodies and by ascertaining the quantity of gas produced, 
the urea is estimated. 

The ureometer of Doremus is a simple and useful instrument. It 
consists of a bulb and graduated tube, and a small curved 
pipette, to hold 1 ccm. of urine. The tube is filled with hypobromite 
solution of the usual strength to the mark indicated on the Jong 
arm of the apparatus and then water is added to fill the rest of the 
arm and lower part of the bulb. The pipette filled with urine is 
then introduced as far into the bend as it will go and the nipple 
compressed to expel all the urine. The tube is so graduated that 
each of the small divisions = .001 gram of urea. The percentage 
can be obtained by multiplying the weight of the urea used as 
indicated by the graduation on the glass by 100. The simple 
apparatus of Squibb is sufficiently accurate for clinical purposes. 

Uraemia represents a group of- nervous symptoms caused 
by retention in the blood of the urinary excretory products 
(particularly urea). The mild symptoms of uraemia, are: sleepi- 
ness, headache, nausea, vomiting, dyspnoea (ursemic asthma) and 
Cheyne-Stoke's respiration; severe symptoms: coma, delirium, con- 
vulsions and amaurosis. 

Uric Acid (C 5 H 4 N 4 3 ). — The daily amount passed 
is between 0.2 gram (3 grains) and 1.0 gram (15 grains). 
Nitrogenous food increases and carbohydrates diminish 
uric acid in the urine. It is also diminished during, but 
increased after an attack of gout. It is increased in affec- 
tions of the respiratory (pneumonia, bronchitis, etc.) and 
circulatory systems. It is very much increased in leu- 
caemia. 

Uric acid is slightly soluble in water (1 to 18,000), 
and insoluble in alcohol and ether. The crystals of uric 
acid separated from the urine appear to the naked eye as 
small reddish-brown particles (brick-dust sediment). 
Microscopically (Fig. 14), they present a variety of shapes, 
the most frequent are the whetstone or lozenge form 
rounded off at their obtuse angles. Other forms resem- 
ble barrels, rosettes, combs, etc. 

Test for uric acid (murexide test). — See Urinary calculi, 
Quantitative estimation. Acidulate 200 ccm. of urine with 
10 ccm. of hydrochloric acid and set aside for 48 hours. 
The separated crystals are collected by filtering the fluid, 
then dried and weighed. 



INORGANIC CONSTITUENTS OF URINE. 



145 



Hippuric acid (C 9 H 9 N0 3 ). Daily amount excreted 0.1 — 1.0 
gram (1] — 15 grains). It is increased by a vegetable, and dimin- 
ished by an animal diet. It is readily soluble in alcohol. 
Crystallizes in colorless, long, four-sided rhombic prisms, which 
frequently form stellate bundles. 

Oxalic acid (COO H) 2 . The amount excreted is about 0.02 
grams [}/i — X grain) in 24 hours. It appears in the sediment as 
calcium oxalate in small octahedral crystals, insoluble in acetic 
and soluble in hydrochloric acid. 

Creatinine (C 4 H 7 N s O). About 1.0 gram (15 grains) is daily 
excreted. 

Xanthin and Sarkin, Extractives of the urine allied to uric 
acid in chemical composition, but of no special clinical value. 




Figf. 14 



Fig. 14. a, Crystals of uric acid, b, Urate of soda, c, Calcium 
oxalate, d, Calcium phosphate, e, Triple phosphate, f, Calcium 
carbonate, g, Cystin. h, Leucin. i, Tyrosin. 

Indican. — See color of the urine. 

Phenols. Carbolic acid (C 6 H 5 OH), hydroquinone and cressol 
exist in the urine as the ethereal sulphates. They are increased 
in decomposing processes in the body. 

Test. Add to 100 ccm. of urine, 5 ccm. of concentrated sul- 
phuric acid, and distill the whole in a retort. Bromine water is 
then added to the distillate, and if carbolic acid is present, a 
yellow-white precipitate of tri-bromo-phenol is formed. 



NORMAL INORGANIC CONSTITUENTS. 

The Chlorides. Principally combined with sodium as 
common salt. The amount of sodium chloride excreted 
in 24 hours is about \ the amount of urea present, 
i. e., between 11 and 15 grams (150 — 225 grains), 

M. C. D. 10 



146 MANUAL OF CLINICAL DIAGNOSIS. 

The chlorides are decreased in all acute febrile diseases (espec- 
ially pneumonia) and reappear with convalescence. This is 
particularly the case in diseases accompanied by exudations and 
transudations, which retain the surplus chlorides until their 
formation is complete. 

Test. Add to the urine in a test tube a few drops of nitric acid, 
and then a nitrate of silver solution until no more precipitate forms. 
Precipitate is dense and curdy, if the chlorides are normal ; milky 
if diminished ; and faint if almost or entirely absent. The relative 
amount may be estimated by comparison with a normal specimen 
of urine. 

The Phosphates. Phosphoric acid occurs in the urine, 
in part as sodic and potassic phosphate (alkaline phos- 
phates) and calcic and magnesic phosphates (earthy phos- 
phates). It is derived from the food and from the 
retrograde metamorphosis of tissues containing phosphorus. 
The earthy phosphates are probably increased in diseases 
of the brain, osteomalacia, rachitis, etc. They are 
decreased in chronic spinal affections, dropsy, etc. 

Test for the Earthy Phosphates. Fill a test tube % full with 
urine, and add a few drops of caustic po'ash or ammonia and heat 
until the phosphates precipitate in flakes. The test tube is then 
put on a stand for 15 minutes, and the quantity of the precipitate 
is determined. In an ordinary-sized test tube a deposit 1 cm. high 
represents a normal amount. 

In health the phosphates are held in solution by an acid urine, 
and it is only when the urine has become neutral or alkaline that 
they are deposited. 

Triple Phosphate. (Fig. 14 e.) When urea undergoes decompo- 
sition into ammonium carbonate, this with the. magnesium 
phosphate in the urine, forms ammonio-magnesium phosphate 
(NH 4 Mg POJ. Triple phosphate is recognized (Fig. 14 e.) by 
its large transparent crystals, occurring mostly in triangular 
prisms or feathery crystals. The crystals may be confounded with 
common salt and calcium oxalate. Common salt is only found in 
urine which has been concentrated by evaporation. Acetic acid 
will dissolve triple-phosphate, but not calcium oxalate. The 
crystals of triple-phosphate are usually present in cystitis asso- 
ciated with ammoniacal urine. 

Neutral Phosphate of Calcium (Fig. 14 d.) forms wedge-shaped 
crystals, which unite to form rosettes. 

Magnesium Phosphate forms long quadrilateral plates, with 
rounded ends. 

Sulphuric acid (H 2 S0 4 ). — Daily amount excreted is about 2 
grams (}4 drachm). It appears partly as the sulphates of the 
alkalies, and a small portion as organic sulpho-acids. The sul- 
phates are increased by an animal diet and exertion. 



ABNORMAL CONSTITUENTS OF URINE. 147 

Test for the sulphates. — Acidulate the urine with a few drops of 
nitric acid and add a solution of barium chloride. A precipitate 
of barium sulphate is formed insoluble in water or acids. 

Carbonic acid (C0 2 ). — Present in small quantities in human 
urine. Increased after vegetable food, certain drugs and in 
decomposed urine. Large quantities of the^ carbonates cause 
effervescence of the urine on the addition of acids. 

Calcium carbonate (Fig. 14, f,) exceptionally, forms dumb-bell 
crystals. It is recognized by its effervescence and solubility upon 
the addition of mineral acids, which may be observed under the 
microscope. 



ABNORMAL CONSTITUENTS OF THE 
URINE. 

Albumen. — Albumen occurring in the urine (albu- 
minuria), is usually pathological. The albumens found 
in the urine are ordinarily serumalbumen and serumglobu- 
lin. The quantity of albumen may vary from mere 
traces to 1-2% ('rarely more.) The blood-serum contains 
about 5% of albumen. Albuminuria may be caused by 
affections of the kidney (renal albuminuria), e. g. acute 
and chronic nephritis, amyloid kidney; by hydremic 
conditions of the blood (anaemia, leucaemia) ; in fever and 
acute poisoning; after epileptic attacks and apoplexy 
(transitory albuminuria). 

Physiological albuminuria may occur in the female 
after suppression of the milk, after a diet rich in 
albuminous food (particularly a diet of eggs), increased 
renal blood pressure (after a cold bath), excessive mental 
or muscular exertion and in total absence of sodium 
chloride from the food. 

Albumen may be present in inflammatory affections of 
the urinary tract below the kidney. Under these circum- 
stances it forms part of such fluids as blood, pus and 
secretions from the generative organs; the quantity of 
albumen is usually small, and the formed elements (blood 
corpuscles, pus cells, etc.), usually indicate the source of 
the albumen . 

Renal albuminuria is usually associated with a large 
quantity of albumen and the presence of casts. In 



148 MANUAL OF CLINICAL DIAGNOSIS. 

women albuminuria on account of contamination of the 
urine by vaginal discharge is comparatively frequent and 
errors may be averted by the use of a catheter. 

Qualitative tests.— 1. Heller's test. Add to the urine in a test tube 
some nitric acid allowing it to flow down the sides of the inclined 
test tube, so that the tw T o fluids form separate layers; at their line 
of contact if albumen is present, there is formed a sharply defined 
ring-shaped cloudiness. In very concentrated urine, a precipitate 
may be caused by urates, but in this case, the ring is not so dis- 
tinct and is more toward the surface of the urine. If warmed, the 
cloudiness produced by urates will disappear, but not so if due to 
albumen. 

2. Heat test. — Heat the urine to the boiling point in a test tube 
and add one or two drops of acetic acid or 10-20 drops of nitric acid. 
If albumen be present a w 7 hite opacity will appear. The addition 
of acid prevents the precipitation of the phosphates of the alkaline 
earths and favors the coagulation of albumen, which if present in 
small quantities, would not separate in an alkaline fluid. 

If after the heat test the urine is allowed to stand for 24 hours, 
the quantity of albumen may be approximately determined from 
the degree of precipitation. A slight cloudiness but no precipitate 
occurs, w 7 hen there is less than 0.ul% of albumen present; 0.l'5% 
when the curved part of the test tube is barely filled with albu- 
men; 0.1% when the coagulum in the test tube reaches T V the 
way up; 0.25%, % the way up; 0.5%, K the way up; 1%, % the 
w : ay up and 2%-3% when the w T hole fluid is completely coagulated. 

3. Acetic Acid and Ferrocyanide of Potassium. Add to the 
urine 3-5 drops each of acetic acid and a 10% solution of fer- 
rocyanide of potassium; the minutest traces of albumen are 
demonstrated by the formation of a w T hite cloud. This test indi- 
cates the presence of albumen, globulin or albumose, but not 
peptone. 

4. Picric Acid. The addition to the urire of a saturated 
solution of picric acid will produce a greenish cloudiness. 

5. Biuret Test. The urine is rendered alkaline with caustic 
potash and 1 — 3 drops of a diluted solution of sulphate of copper 
are added. In the presence of albumen, the blue solution acquires 
a violet tinge. 

6. Salt and Hydrochloric Acid. A saturated solution of common 
salt containing 2% of pure hydrochloric acid added to cold urine 
will produce a cloudiness. 

7. Metaphosphoric Acid. One or two drops of this acid added 
to the urine will produce a cloudiness, even when mere traces of 
albumen are present. 

8. Potassio - Mercuric Iodide (Tanrefs reagent). Solution: 
Potassii iodid., 3,32 grams. Hydrarg. bichlorid., 1.35 grams. 
Aquae destillat., q.s, ad. 100 cub. cent. First acidulate the urine 
with acetic acid, then add the double iodide solution drop by drop. 



TESTS FOR ALBUMEN. 149 

This will give a precipitate when there is only 1 grain of albumen 
to a quart of water. 

Quantitative Tests. — (Esbach's Albuminometer) . This consists 
of a test tube marked at its upper end with U and R and at the 
bottom with 1, 2, 3, 4, 5, 6, 7. The urine is added up to U and 
the reagent (picric acid 10 grams, citric acid 20 grams, water 10('O 
cub. cent.) to R. The tube is well shaken, and after standing 24 
hours the l^vel of the precipitate is read off, the number on the 
scale representing grams of albumen per liter. To obtain the 
percentage the respective figure is divided by 10. When the 
albumen is abundant the urine is first diluted with one or two 
volumes of water, and then multiplying the resulting figures by 2 
or 3, as the case may be. 

Tanrefs method. To 10 cub. cent, of filtered urine add 2 cub. 
cent, of acetic acid diluting with a little water; next add Tanret'8 
reagent (see above) drop by drop, counting the number of drops 
used ; when the precipitate thus formed grows less, a drop of the 
urine is taken out and brought in contact with a few drops of a 1% 
solution of corrosive sublimate on a porcelain plate; if on mixing 
the two, a red precipitate occurs, the reaction is complete, and 
for each drop of the reagent used, less 3 drops allowed for excess, 
0.5 grams of dry albumen per liter are present. 

Method by Weighing, Pour 100 cub. cent, of filtered urine into a 
beaker and add a drop or two of acetic acid ; heat on water bath 
for half an hour or more ; collect precipitate, wash with alcohol 
and ether, then dry and weigh. The weight, less that of the 
filter, represents the percentage of albumen. 

Peptones. Present in the urine {peptonuria) during the absorp- 
tion of pus and the formation of exudations (pneumonia, abscesses, 
etc.). 

Peptones are detected by the Biuret test after albumen or hemi- 
albumose has been removed or proved absent. 

Hemialbumose ( propeptone) . Rarely present in the urine, 
but found in osteomalacia and intestinal tuberculosis. 

Test for Hemialbumose. Acidify the urine with a few drops of 
acetic acid and add J its volume of a concentrated salt solution ; 
boil and filter off the precipitate. Albumen and globulin remain 
on the filter. The filtrate is allowed to cool, and if a turbidity 
arises by the further addition of the salt solution, which disap- 
pears by heating and reappears on cooling, then hemialbumose is 
inferred to be present. 

Fibrin is present in the urine in cases of hematuria, 
chyluria, tuberculosis of the gemto-urinary tract, etc. 

It is recognized by spontaneous coagulation in the urine. 

Mucin. — Occurs in traces in normal urine. Increased 
in diseases of the urinary passages. It is precipitated 
by alcohol and dilute mineral acids but not by heat. 



150 MANUAL OF CLINICAL DIAGNOSIS. 

Test. — If acetic acid is added to cold urine a cloudiness 
or precipitate appears which is not dissolved by an excess 
of the acid if mucus is present. 

Blood. — Blood in the urine, differs in appearance 
according to the part of the urinary tract from whence it 
is derived. If from the renal parenchyma, the blood is 
well mixed with the urine giving it a smoky appearance; 
it appears in small quantities and renal casts are pres- 
ent. From the ureters, long semicircular clots and strings 
are present. Prom the urethra and bladder, the quantity 
of blood is large and blood clots are present. 

Tests for Blood. Spectroscope. — Two dark absorption bands 
in D and E of the spectrum, i. e., in the yellow and green, the 
former being narrower, the latter broader (oxyhemoglobin). 

Heller's Test. — If the urine be heated with caustic potash, the 
earthy phosphates in precipitating carry down the blood-coloring 
matter and appear reddish brown instead of white. 

Almen's Test. — Add to the urine a few drops of fresh tinc'ure of 
guaiac; after shaking, add a few drops of resinous turpentine oil. 
If haemoglobin is present, the color will change to a distinct blue. 
The following mixture may be employed in place of turpentine 
oil : Glacial acetic acid, 30 drops ; Distilled water, 15 drops ; Oil of 
turpentine, absolute alcohol, chloroform, — of each 3 ounces 
(Hiihnerfeld's mixture). 

Microscopic Examination. — Teichmann's test (See Blood) may be 
conducted with the urinary sediment. 

The most trustworthy evidence of blood in the urine even when 
the foregoing tests prove negative, is the recognition in the sedi- 
ment of red-blood corpuscles under the microscope. When the 
corpuscles are pile as occurs in dilute urine, the addition of eosin 
or iodine in solution will deepen their color. 

Bile. — Biliary matters in the urine may be caused by 
hepatogenic or haematogenic icterus (See pages 5 and 6). 
In the former, resulting from obstruction of the bile ducts, 
the biliary coloring matter as well as the biliary acids are 
present in the urine. In haematogenic icterus, the biliary 
coloring matter is present but not the biliary acids. 

Tests for Biliary Coloring Matter. — Grnelin's test. — To the urine, 
yellow nitric acid is added in a manner to cause the two to form 
different layers; there will be a play of colors from green, blue, 
violet, red to yellow. The colors appear in the order mentioned. 
A blue ring alone may be caused by indigo, a reddish-brown one 
by hydrobilirubin and other substances. 

MarechaVs Test. — If a solution of iodine in iodide of potash be 
added to the urine, so that the two fluids may touch but not 



TESTS FOR BILE AND PUS. 151 

mix, a green color will immediately develop below the layer of 
iodine. 

If urine containing biliary coloring matter is shaken with 
chloroform, the latter becomes yellowish. The chloroformic solu- 
tion of the bile pigment, may then be tested after Umehn's 
method. 

In all these tests, darkly-colored urine should be diluted with 
water before applying the test. Albumen does not interfere with 
the tests. 

Tests for Biliary Acids. — Pettenkofer'stest. — Unless applied in the 
following manner the results are usually negative: Evaporate 
about 6 ounces of the urine to dryness in the water bath. Extract 
the residue with absolute alcohol, filter, and add ether in excess 
(20 times the bulk of alcohol used). By this means the biliary 
acids are precipitated. The precipitate is removed by filtering, 
redissolved in distilled water and then decolorized by filtering 
through animal charcoal. The filtrate is now ready for the test; 
a single drop of a solution of syrup of cane-sugar diluted with 
water, is added to the filtrate in a test tube; sulphuric acid is then 
added drop by drop, while the test tube is immersed in cold 
water ; a fine cherry -red or purple-violet color appears. 

Method of Strassburg. Some cane sugar is dissolved in the 
urine, and a piece of filtering: paper is then dipped into this and 
allowed to dry. If the filtering paper is now touched with con- 
centrated sulphuric acid, a violet-red spot appears. 

Pus. — Pus in the urine (pyuria) may arise from an 
inflammatory affection in some part of the urinary tract, 
or the communication therewith of abcesses. Pus arising 
in the urethra may be squeezed out by pressure, and 
usually escapes with the first portion of the urine. Pus 
from the bladder is accompanied with hypogastric pain, 
frequent urination, alkaline urine; and the quantity of 
pus is large. Pus from the pelvis of the kidney is small in 
quantity, and the reaction of the urine is usually acid. 
Pus from the kidney is small in quantity, and the 
urine is acid, as a rule ; renal casts are found in the 
sediment, and the amount of albumen is always greater 
than can be accounted for by the pus present. There are 
also symptoms of renal disease. The localization of sup- 
purative changes is aided by the character of the epithe- 
lium found in the sediment. In pyuria arising from 
affections above the bladder, there is a notable absence of 
mucus. 

Tests.— Donne's Test. Pour off the supernatant urine, and to 
the sediment add liquor potassae; the pus is changed to a gela- 
tinous, ropy mass. 



152 MANUAL OF CLINICAL DIAGNOSIS. 

Microscope. Pus cells are j£ larger than red-blood corpuscles, 
and granular. Granules disappear, and a group of nucleoli 
appear, on the addition of acetic acid. 

Grape Sugar. — (dextrose) C 6 H 12 6 , occurs in 
traces, in rormal urine (about 0.5 gram in 24 hours). 
The temporary presence of small quantities of sugar in 
the urine (under \%) is without diagnostic importance, 
and occurs in health after a diet rich in carbohydrates 
(transitory glycosuria). It is persistently present in 
larger quantities in diabetes mellitus. The urine in this 
affection is increased in quantity, is clear, pale, of high 
specific gravity, and contains an increased quantity of 
urea. Glycosuria (temporary presence of sugar in urine) 
occurs : after poisoning (curare, nitrite of amyl, chloral, 
etc.)? i n acute infectious diseases, affections of the medulla 
oblongata, after epileptic attacks, etc. 

Qualitative Tests. In the following tests if albumen is present it 
is first separated by boiling and filtration. _ 

1. Moore's Test. Heat the urine a few minutes with J its volume 
of liquor potassce, when, if sugar be present, a yellowish -brown 
color appears, which is darker the larger the quantity of sugar 
present. On adding dilute sulphuric acid, the smell of burnt 
sugar (caramel) is perceptible. This test is now little used, 
because, for its success, 0.3% of sugar must be present. 

2. Trommer's Test. Add to the urine x / 2 or 3^ volume of liquor 
potassw and a few drops of a 10% solution of cupric sulphate. Heat 
test tube in its upper half to boiling, and if sugar is present, there 
will be a reddish-yellow precipitate of cuprous oxide. 

3. Fehling's Test. — Solution ; crystalline sulphate of copper, 520 
grains, neutral tartrate of potash, b% ounces, officinal caustic 
soda solution, 3 ounces, distilled water to make 30 ounces. 

This solution is diluted with 3 to 4 volumes of water, heated to 
the boiling point (should remain clear, otherwise to be discarded) 
and a little urine added. If sugar is present, a yellowish red 
precipitate of cuprous oxide will form. 

Fehling's Method modified by See gen. — Urine is filtered through 
a t v dck layer of animal charcoal (of blood) which absorbs the whole 
of the sugar ; the charcoal is washed out with distilled water which 
dissolves^out the sugar, which may be tested with Fehling's solu- 
tion; traces of sugar may be found even in the 4th washing. 

4. Bismuth Test (Bottger). — Add an equal quantity of liquor 
potassce to urine and a small quantity of bismuth sub nitrate ; boil 
for a minute or two, and if sugar is present, the bismuth salt is 
reduced and a brown or black color is formed. With this test, 
albumen or sulphides in the urine, produce similar effects as 
sugar. Nylander's modification of this test consists in the use of the 
following solution: Bismuth subnitrate, 2 grams, rochelle salt, 4 



TESTS FOli SUGAlt. 153 

grams, 8% solution of sodium hydrate, 100 grams. With this solu- 
tion, urine containing sugar turns brown or black after boiling. 

5. Mulder's Test.— Xiter the urine is rendered alkaline with car- 
bonato of sodium, a solution of indigo carmine (sulphate of indigo) 
is added until the urine turns blue. On heating, indigo blue is 
changed to indigo wdiite and on exposure to the air turns blue 
again. 

t>. Phenylhydrazin Test. — This test is based on the power of 
phmylhydrazine to unite with grape sugar and form characteristic 
crystals. To a measuring beaker half full of water add 2 drachms 
of hydrochloric phenylhydrazine and three of sodium acetate; the 
compound having been heated, the same quantity of urine is added 
and placed iu a vessel of boiling water for 15 minutes; it is then 
quickly put in cold water. After standing for some minutes, a 
yellow crystalline sediment of phenyl glucosazone slowly falls. If 
only a little grape sugar is present, then the sediment under the 
microscope shows yellow rod like crystals terminating at each end 
in round balls or bunches. 

7. Molisch's Method — Menthol, thymol or alpha-naphthol are used 
in their alcoholic solutions (1 to 7 alcohol) by mixing a few drops 
with the urine. To the mixture sulphuric acid is added so that the 
solutions do not mix ; if sugar is present a red color (if thymol or 
menthol was used) is produced at the line of contact, or if alpha- 
naphthol was employed, a violet color with greenish borders. 

8. Johnson's Method. — If a few drops of picric acid are added to 
the urine, which is then mixed with an alkaline hydrate, a deep 
red color appears if sugar is present. A light red color appears in 
normal urine. 

The most reliable tests at present known to us, are Nylander's 
modification of the Bismuth test and the Phenylhydrazin test. 
In the former test, one part of the solution is taken to ten parts of 
the urine, which is boiled one minute, but never exceeding two 
minutes, when a dark solution will be obtained on cooling from 
the oxidation of the bismuth. This very sensitive test detects 
the presence of 0.08% of sugar. 

Quantitative Tests for Sugar.— 1. Fermentation. This test 
depends on the decomposition in the urine of sugar by the torula 
cerecisice (veast plant) with corresponding reduction of the 
specific gravity of the fluid. After taking the specific gravity 
pour 4 ounces of urine into a bottle to which is added a piece of 
yrast about the size of a pea ; the bottle is then loosely corked and 
set aside in a warm place for 24 hours, w r hen fermentation will be 
completed. Allow the bottle to cool, and then take the specific 
gravity again. The difference gives the number of grains of sugar 
to the ounce. 
Example : 

Specific gravity before fermentation = 1040 
Specific gravity after fermentation = 1015 

Difference = 25 



154 MANUAL OF CLINICAL DIAGNOSIS. 

25 grains of sugar are present to the ounce. The percentage ia 
obtained by multiplying this number by 0.23. This method is the 
most certain test for su^ar. It is well, in making the test to have 
two other bottles, one containing a solution of grape sugar and a 
little yeast (to show that the, yeast is active) , the other containing 
nc rmal urine and yeast (to show that the yeast is free from sugar). 

Fehling's method. Mix in a flask or beaker 10 c. c. of Fehling's 
solution (see Fehling's test) diluted with 40 c. c. of distilled water. 
Heat to boiling, and add from a burette containing a mixture of 
one part of urine and nine of water, a little at a time, stirring the 
mixture until the blue color of the te-t solution has entirely dis- 
appeared. As 10 c. c. of Fehling's solution are reduced by 0.05 
grams of sugar, that amount of diluted urine which has reduced 
10c. c. of Fehling's solution contained 0.05 grams of sugar. If 16 
c. c. of diluted urine (1 in 10) were used, 1.6 c. c. of urine con- 
tained 0.05 grams of sugar. The percentage is obtained by the 
following proportion : 1.6 :0. 05 = 100 :x ; x=3. 1 per cent. 

By means of the polariscope, the quantity of glucose is readily 
ascertained, but the apparatus requires great care in adjustment, 
and errors are liable owing to the presence of other bodies allied 
to sugar. 

Inosite (C 6 H 12 6 ). Muscle sugar is present in the 
urine of renal disease and diabetes insipidus. It does not 
ferment, precipitate copper salts or affect polarized light. 

Acetone (CH 3 COCH 3 ). May be found in normal 
urine. Increased in febrile diseases, in certain forms of 
diabetes, affections of the brain, etc. It is looked for in 
diabetic coma, in which condition it imparts a vinous 
odor to the breath and urine. 

Tests. Perch loride of iron with acetone gives a Burgundy-red 
color (unreliable). 

Ziehen's Test. Twenty grains of potassium iodide are dissolved 
in one drachm of liquor potasses and boiled. The urine is poured 
on the surface of this solution producing at first a precipitation 
of the phosphates, but if acetone is present the deposit becomes 
yellow, owing to the development of iodoform, which is recognized 
by its characteristic odor. 

LegaVs Test. Add to the urine a few drops of freshly prepared 
nitro-ferrocyanide of sodium and then caustic soda until it is 
strongly alkaline. When the beginning purple tint turns yellow, 
1-3 drops of acetic acid are added, and if the acetones are present 
a crimson-purple color is formed at the point of contact of the 
acetic acid and the mixture. 

EhrlicWs Diazoreaction. — This reaction present in 
typhoid fever and in relapses of this affection is of some 
value in doubtful cases. Its disappearance is a good sign. 



ORGANIC SEDIMENTS. 155 

It is also present in severe cases of phthisis, pneumonia 
and measles. 

Test. Solution 1. Sulphanile acid, 5 grams, muriatic acid, 
50 grams, distilled water, 1000 grams. Solution 2. Nitrite^ of 
FoUum 0.5 grams, water, 100 grams. Take 50 ccm. of solution 
1 and 1 ccm. of solution 2 and mix in a test tube with an equal 
quantify of urine to which is added % volume of ammonia, and 
the whole well shaken. The reaction is positive when a red color 
is formed, especially noticeable in the foam. 

The "Diazo" reaction constitutes one of the earliest and most 
constant signs of typhoid fever. Febrile abdominal catarrh never 
shows this reaction. Disappearance of the reaction points to 
approaching apyrexia. Relapses are almost invariably accom- 
panied by its reappearance. 

Sulphuretted Hydrogen (H 2 S). Present in decom- 
posed urine. 

Test. Filtering paper saturated with acetate of lead 
solution when held over the bottle turns black (formation 
of lead sulphide). . 

Cystin. Occasionally found in urine. Under the 
microscope it appears as colorless, shining, six-sided 
plates or prisms (Fig. 14). 

Leucin and Ty rosin. Found in acute yellow atrophy of 
the liver and in phosphorus poisoning. 

Under the microscope leucin appears as yellow-colored 
spheres, at times concentrically striated with protruding 
points (Fig. 14). 

Tyrosin appears in white needles arranged in bundles. 
To obtain these crystals for microscopical examination 
the urine is evaporated to a syrupy consistency. 



ORGANIC SEDIMENTS. 

White Blood Corpuscles (leucocytes). Normally pres- 
ent in small numbers. Increased in inflammation and 
suppuration of the genito-urinary tract (nephritis, pyelitis, 
cystitis, urethritis and leucorrhcea). 

Red Blood Corpuscles. Present in hematuria. They 
are usually pale, and may appear as casts. 

Renal epithelium. Round or cuboid cells with a vesic- 
ular nucleus and often full of fat drops (Fig. 15, i). 



156 MANUAL OF CLINICAL DIAGNOSIS. 

Arranged in cylindrical form they make epithelial casts. 
Renal epithelium nearly always indicates an affection of 
the kidney. 

Epithelial cells from the renal pelvis, ureters and bladder cannot 
be differentiated from each other. The cells of the superficial 
layers have a polygonal form, while those of the deeper layer are 
round, with processes, and contain a vesicular nucleus. An 
increase of these cells in the urine may indicate cystitis, pyelitis 
or inflammation of the ureters. The vagina and prepuce have 
pavement, and the male urethra cylindrical epithelium. 

Casts. These are moulds of the renal tubules produced 
by the escape of a coagulable material which coagulates 
and entangles other substances, and are characteristic of 
renal disease. They may be divided according to com- 
position and appearance into three groups (v. Jaksch). 
1. Cellular. 2. Those composed of products of degenera- 
tion. 3. Hyaline. 

1. The cells found in casts are red-blood corpuscles, 
leucocytes, renal epithelium and sometimes colonies of 
bacteria. 

2. The products of degeneration are granules derived 
from epithelial dSbris, amyloid material and fat. 

3. Hyaline cylinders are composed of the ground sub- 
stance only. 

Blood Casts (Fig. 15, b) are red-blood corpuscles held together 
by coagulation. They are a certain sign of renal hematuria. 

Leucocyte casts may occur in purulent affections involving the 
renal tubules. 

Epithelial casts (Fig. 15, a) are composed essentially of renal 
cells embedded in a hyaline albuminoid substance. 

Casts of Bacteria are present in septic embolic nephritis or 
pyelo-nephritis. With a low power they resemble granular casts. 

Granular casts (Fig. 15, d) are composed of granules, which 
consist of broken-down blood or epithelial cells. 

Fatty casts are usually hyaline casts dotted with oil globules. 
Any cast covered with oil drops is known as a ' 'fatty cast." 
These casts may indicate fatty degeneration in the kidney. 

Amyloid casts are transparent, homogeneous and very brittle, 
and stain deeply with a solution of iodine. 

Hyaline casts (Fig. 15. c) are colorless, very long and narrow. 
They are easily overlooked, and it is advisable in searching for 
them as well as other casts to add a drop of Lugol's solution or 



CASTS W TUB URINE. 



15*> 



aniline red to make them more distinct. These casts have beek 
occasionally found in normal urine. 

Mucous casts of the uriniferous tubules are usually very long, 
and when present do not necessarily indicate disease. 

Casts of the seminal tubes are very rare, and are usually of 
greater calibre than renal casts. 

Casts of Ammonium Urate (Fig. 15, f) are commonly found 
during the first days of life in children. Treated with potassium 
hydrate, ammonia escapes, and the casts disappear. 




Fig. 15. 

Fig. 15. a. Epithelial cast. b. Blood cast. c. Hyaline cast, 
d. Granular cast. e. Waxy cast. f. Cast of ammonium urate. 
g. Pavement epithelium from the bladder (upper layer), h. 
Same (lower layer), i. Epithelial cells from the uriniferous 
tubules. 



Spermatozoa may be found after coitus, nocturnal emissions, 
spermatorrhoea, etc. Found in the urine of women they may be 
of medico-legal importance. Fragments of morbid growths may be 
met with in the urine. 

Micro-organisms are present in many infectious diseases 
(diphtheria, recurrent fever, etc.). 



158 MANUAL OF CLINICAL DIAGNOSIS. 

Tubercle bacilli are present in tuberculosis of the genito- 
urinary tract, and gonococci in gonorrhoea. 

In examining for the tubercle-bacilli, the method is the Fame as 
that detailed elsewhere {see Sputum). A number of cover-glass 
preparations from the sediment of the urine must be made. 

Animal parasites are occasionally found in the sediin-nt. The 
shreds or hooklets of echinococci occur in the urine when this 
parasite affects the kidney. 

The Listoma haematobium inhabits the small veins of the kidney 
and portal system and the ova are expelled with the urine accom- 
panied by biood. 

In chyluria, the Filaria sanguinis has been found at times in 
the urine, but it is more constantly present in ihe blood. 

Non pathogenic organisms develop in uri^e exposed to the air. 
In urine containing sugar, the yeast plant {Torula cerevisi&j often 
occurs. 



SECRETIONS OF THE MALE GENERA- 
TIVE ORGANS. 

Semen. Semen is a complex fluid composed of secretions 
of the testicles, of the seminal vesicles, of the accessory 
glands of the urethra, especially the prostate, Cowper's 
glands, and the glands of the mucous membrane 
of the urethra. With the microscope, spermatozoa, 
spermatic cells, epithelium from the prostate and urethra 
and seminal granules can be distinguished. In fresh 
semen, the motion of the spermatozoa is very active. 
The amount of semen discharged at a single evacuation 
varies from 5-10 grams. 

Pathological Changes. Absence of semen (Aspermia) may be 
congenital or acquired. Acquired permanent aspermia may follow 
occlusion of the ejaculatory ducts or destruction of the glandular 
tissue of the prostate gland. Temporary aspermia may occur with 
a comparatively normal state of the sexual apparatus. 

Polyspermia. An increase in the amount of semen discharged 
at a single ejaculation is relatively seldom observed. 

Oligospermia signifies a decrease in the amount of semen 
discharged. Observed in advanced age, and after inflammation 
of the testicles and diseases of the prostate. 

Oligozoospermia. Signifies a diminution in the number of sper- 
matozoa, while azoospermia means their total absence. Oli^ozoo- 
spermia is most frequently caused by gonorrhceal inflammations 
of the epididymes and spermatic cords. 










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SECRETIONS OF MALE GENERATIVE ORGANS. 159 

Secretion of the Prostate. This is a milky fluid show- 
ing under the microscope cylindrical epithelial cells 
white blood corpuscles, amyloid bodies and glistening 
granules. If a few drops of a 1% solution of phosphate 
of ammonia is added to the fluid under the microscope, 
spermatic crystals are formed. 

Prostatorrhcea signifies involuntary loss of the prostatic 
secretion. It occurs in all irritable conditions of the 
prostate, whether produced by gonorrhoea, masturbation' 
or senile hyperplastic alterations of the gland. 

Secretion from the Glands of Cowper is an odorless, 
clear viscid fluid, showing under the microscope epithelial 
and round cells. This secretion normally appears during 
erection of the penis as a clear, transparent drop at the 
meatus. 



CHAPTER XII. 

THE NERVOUS SYSTEM. 

Anatomy and Physiology of the Brain and Spinal Cord. — The 
cerebral cortex i. e. the gray matter upon the surface of brain is 
the seat of mental activity. It has ridges (gyri or convolutions) 
and depressions {sulci or fissures). The psycho-motor region of the 



^^4obuhis paracenfralis 




Fig. 16. 



cortex (motor area) comprises the anterior and posterior convolu- 
tions and the lobus paraceniralis of either hemisphere {this area is 
shaded in Fig. 16). 
( 160) 



PSYCHO-MOTOR REGION, PYRAMIDAL TRACT. 161 

When certain limited areas of the brain cortex are stimulated by 
electricity in animals, according to the area stimulated, move- 
ments of definite nmsole-gronpa can be evoked, which is not the 
case when these areas are extirpated. 
The excitable areas of the cortex are as follows : 

1. The region of the arm lies in the middle third of the anterior 
convolution (G. centralis ant.) 

2. The region of the leg lies in the upper third of the central 
convolutions and the lobus paracentralis. 

3. The region of the head lies in the lower third of the central 
convolutions and that portion of the frontal convolution bordering 
on the fissure of Sylvius. 

4. Region of the trunk, convex surface of the frontal lobe border- 
ing on the pne<entral fissure. 

5. Center of vision, occipital lobes. 

6. ('enter of hearing, temporal lobes. 

7. Center of speech, inferior frontal convolution {left side) and 
adjacent area, around the low r er part of the fissure of Sylvius. 

The cortex of the parietal lobes is associated with the sensory 
tract. 

Pyramidal Tract (Fig. 17). From the cortical centres the 
motor fibres converge toward the large ganglia at the base of the 
brain, where they present a white strand of fibres (internal cap- 
sule). 

That portion of the capsule in front of the head of the caudate 
nucleus and behind the lenticular nucleus, constitutes the anterior 
limb of the internal capsule. As the capsule passes along the 
internal margin of the lenticular nucleus it makes a bend (genu) 
and runs between the front of the optic thalamus and behind the 
lenticular nucleus, forming the posterior limb of the internal 
capsule. From the internal capsule, the motor fibres pass into 
the pons and from the pons into the medulla forming the 
pyramidal bodies. 

At the low T er part of the medulla, about 10% of the fibres pa ss down 
the same side of the spinal cord in the anterior pyramidal tracts, 
whereas the other fibres (crossed fibres) pass to the opposite side of 
the cord into the lateral pyramidal columns. From these columns 
the fibres pass into the ganglionic cells of the anterior horns, and 
from these cells the anterior roots of the spinal cord are formed 
which send motor fibres to the muscles. The centers of the 
cerebral cortex control the nutrition of the pyramidal tracts up to 
the point where they enter the ganglia of the anterior horns of 
the cord, whereas the ganglia of the anterior horns control the 
nutrition of the peripheral motor nerves and muscles. 

Lesions of the motor tract result not only in motor paralysis but also 
in descending degeneration of the pyramidal tracts, inasmuch as 
their trophic center is in the cerebrum. The trophic center of the 
peripheral motor nerves is situated in the ganglionic cells of the 
anterior horns, hence lesions here result in degeneration of the 
nerves, and paralysis and atrophy of the affected muscles. 



162 



MANUAL OF CLINICAL DIAGNOSIS. 



The Sensory or Centripetal tract takes its origin in the sensory 
nerves of the periphery which reach the cord through the posterior 
or sensory roots which on their entrance immediately cross over 
to the opposite side. 




Fig. 17. 
Fig. 17. Diagrammatic Transverse Vertical Section of the 
Cerebrum — (After Schwalbe) . 



co, cortex 

coi, island of Reil 

cl, claustrum 

na, nucleus amygdalae 

nc, caudate nucleus 

th, optic thalamus 

cm, middle commisure 

cs, subthalamic body 

m, substantia nigra 

nl, lenticular nucleus 



ci, internal capsule 

ce, external capsule 

stt, stria terminalis (taenia semi- 
circularis) 

cf, anterior pillar of the fornix 
/, fornix 

cc, corpus callosum 
villi third ventricle 
vl, lateral ventricle 
to, optic tract 



DIAGNOSIS OF BRAIN LESIONS, 163 

The blood supply of the brain is derived from the internal 
carotid and vertebral arteries. Each carotid divides into the 
anterior cerebral and middle cerebral arteries. The middle 
cerebral artery enters the fissure of Sylvius and sends branches to 
the lenticular nucleus and adjacent parts of the brain, including 
the caudate body ot the corpus striatum, optic thalamus and 
internal capsule. The anterior and middle cerebral arteries 
do not freely anastomose, and are called terminal arteries. 

Anterior pyramidal tract. 
Anterior 




Spinal Cord (Fig. 18). The Anterior and lateral pyramidal 
tracts of each side contain only motor fibres. Those in the former 
[Turk's columns) are connected with the corresponding cerebral 
hemisphere; the latter (crossed pyramidal tracts) with the oppo- 
site cerebral hemisphere. The posterior columns (tracts of Gull 
and Burdach) convey sensory nerve fibres. 

Diagnosis of Brain Lesions. — Lesion of the internal 
capsule: there is hemiplegia or hemianesthesia (loss of 
sensation in one lateral half of body) or both combined; 
hemiparalysis of the lower half of the face. Tremor, 
hemichorea and athetosis. 

Lesions of the cms cerebri: if the lesion is confined to 
the tegmentum cruris (sensory portion), there is hemian- 
esthesia of the opposite side of the body and paralysis of 
the 3d and 5th cranial nerves on the same side. If the 
motor portion (crusta cruris) is alone implicated, there is 
paralysis of the 3d nerve with hemiplegia on the opposed 
side. 

Corpora Quadrigemina : incoordination of movement, 
absence of pupillary reflex, nystagmus and strabismus. 
Blindness may exist independent of a choked disc, optic 
atrophy or neuritis. Pons varolii; lesions may be above 
or below the line of Gubler. This is an imaginary line, 
that connects the apparent origin of the trigeminal roots 
and marks the level of the decussation of the facial nerve 



164 MANUAL OF CLINICAL DIAGNOSIS. 

fibres that pass ccphalad. Lesion above the line of Gubler: 
facial paralysis and hemiplegia upon the same side of the 
body and opposed to the seat of lesion. Below the line of 
Gubler: facial paralysis on the same side as the lesion 
and hemiplegia on the opposed side. Cerebellum: inco- 
ordination of movement, intense vertigo and titubating 
gait. Only when the vermiform process is implicated 
are the symptoms of cerebellar lesions pronounced. Me- 
dulla oblongata: disturbances of respiration, circulation, 
phonation, deglutition and articulation (when cranial 
nerve roots are implicated). Diabetes and albuminuria 
may be present. Lesions at the base of the brain (anterior 
fossa): implication of the olfactorius. Middle fossa: 
implication of the opticus, oculomotorius, trochlearis and 
abducens. Posterior fossa: implication of the trochlearis, 
abducens, facialis, acusticus, gl^sso-pharyngeus, vagus, 
accessorius and hypoglossus. Basal lesions may also 
involve the pyramidal tracts. 

Lesion of the thalamus opticus : post-hemiplegic chorea, 
athetosis, and tremor of the paralyzed limbs. Hemian- 
opsia. 

Diagnosis of Spinal Lesions. — Lesions of the cord 
before pyramidal decussation cause paralyses of the same 
side. Usually lesions of the spinal cord affect both sides 
alike leading to paraplegia, a frequent form of spinal 
paralysis. In cases of transverse section of the cord, the 
columns of Goll and cerebellar lateral tracts degenerate up- 
ward from the point of injury and the pyramidal columns 
downward. Lesions of the spinal cord are systematic and 
non-systematic or focal. The former refer to affections 
limited to recognized subdivisions of the spinal cord 
without spreading to adjacent parts; by the latter is 
meant affections not limited but which spread as the 
lesion progresses. In. Tabes dorsalis the lesion is in the 
posterior columns; Lateral sclerosis: lateral columns, 
Amyotrophic lateral sclerosis: anterior cornua and lateral 
columns ; Acute anterior poliomyelitis (infantile spinal 
paralysis): anterior cornua; Progressive muscular atrophy : 
anterior cornua. In bulbar paralysis there is degenerative 
atrophy of the nuclei of nerves of the medulla oblongata. 



PARALYSIS. 165 

Paralysis. — When the movement of an extremity is 
entirely absent, the term paralysis is used; when slight 
movement is possible, paresis. 

Paralysis may be cerebral, spinal or peripheral. 

Hemiplegia signifies paralysis in one lateral half of the body. 
Paraplegia signifies paralysis of both legs or arms. Hemi-paraple- 
gia: parjlyeis of motion in the lower one-half of one lateral half 
of the body. Monoplegia: paraVsis of a distinct group of muscles. 
Central paralysis: lesions of the motor tracts proximal to the 
anterior horns of the cord. Peripheral paralysis: lesions of the 
motor nerves peripheral to the anterior horns of the cord. Flaccid 
paralysis: when the paralyzed limb readily yields to passive move- 
ment. Spastic paralysis: when the paralyzed limb offers a resist- 
ance to passive movement. Spastic paralyses are usually 
associated with # exaggerated reflexes. Functional paralysis (no 
anatomical lesion) : are usually unattended by trophic or 
electrical disturbances. 

Cortical Paralysis. — This is due to some lesion (abscess, 
blood clot, tumor, embolism, meningeal thickening, 
depressed bone, etc.,) of the cerebral cortex. Cortical 
lesions may be irritative or destructive. 

Irritative lesions are usually connected with paroxysmal cramps 
in £ome special group of muscles (cortical or Jacksonian epilepsy). 
Paralysis if present is usually transient and returns after subse- 
quent paroxysms. 

In destructive lesions there is paralysis of special groups of mus- 
cles {monoplegia). Consciousness is not lost as in lesions of central 
portions of the brain. Pain within the head in these lesions is 
usually localized or percussion over the seat of the lesion will elicit 
it. No impairment in sensibility of the paralyzed parts exists, 
unless sensory paralysis is present as a complication. Affected 
muscles show normal electro-contractility. Paralysis (as in other 
cerebral lesions) is on the side opposite to the lesion. 

Hemiplegia (seat of lesion). If intra-cranial, the paral- 
ysis is on opposite side of body; if spinal, on the same 
side. 

Symptoms. Seat of Lesion. 

Hemiplegia with motor aphasia. 3d left frontal convolution. 

" " paralysis of Posterior limb of internal cap- 
lower facial sule. 
branches. 
M " hemianses- Posterior third of internal cap- 

thesia. sule. 

11 " crossed paral- Crus cerebri on same side as 

ysis of 3d cran- paralyzed nerve, 
ial nerve. 

•* " crossed facial Pons, 
paralysis. 



166 MANUAL OF CLINICAL DIAGNOSIS. 

Etiology. 1. Embolism. 2. Apoplexy. 3. Syphilis. 4. Toxic 
In embolism, the paralysis is usually sudden without loss of con- 
sciousness and usually associated with motor aphasia,. There is 
usually a heart lesion. Patient usually young. 

Apoplexy. Origin sudden with loss of consciousness and usually 
associated with lower facial paralysis. Arteries atheromatous and 
patient is usually old. In the stage of reaction, there is a rise of 
temperature (from inflammatory changes around the clot.) 

Syphilis. Origin slow. Lesions multiple. History of syphilis. 
Good results from anti- syphilitic treatment. Occurs in the young. 

Toxic. In uraemia and the later stages of phthisis and carci- 
noma (hemiplegia is transitory). 

Paraplegia (seat of lesion). When the paralysis is 
incomplete the term paraparesis is used. 

Lesion may affect lumbar (frequent), dorsal or cervical 
region (paralysis of all four extremities). 

Etiology. Myelitis, trauma, carcinoma, tuberculosis, 
caries and syphilis. 



PARALYSIS OF THE CRANIAL NERVES 

1. Olfactorius. Loss of smell (anosmia). Test with asafcetida, 
etc. 

2. Opticus. Diminished sharpness of vision and sense of color ; 
narrowing of the field of vision (examine with ophthalmoscope). 

Loss of vision in one lateral half of each retina is called hemi- 
anopsia. The most common form is homonymous hemianopsia, 
when nasal half of one eye and temporal half of the other eye is 
blind. This may result from some lesion of the optic tracts or the 
cortex of occipital lobe. The binasal variety indicates a lesion of 
the chiasm. Total blindness (amblyopia or amaurosis) is due to a 
lesion of the opticus peripheral to the chiasm. 

Hemianopsia may be detected by requesting the patient to close 
one eye and to fix the open eye on some near object. Now take 
some object easily seen and move it to the right and left and rUo 
above and below the object upon which the patient is gazing, 
asking the patient in each case if the two objects are seen 
distinctly and simultaneously. The retina is blind upon the side 
opposite to that upon which the moving object is lost to sight. 

3. Oculomotorius. Falling of the upper eyelid (ptosis), external 
strabismus, dilatation and absence of the pupillary reaction, 
double vision (diplopia) and disturbances of accommodation. 

4. Trochlears. Eye cannot be raised or rotated outwards. 



PARALYSIS OF CRANIAL AND SPINAL NERVES. 167 

5. Trigeminus. Anaesthesia of the sensory distribution of this 
nerve; paralysis of the masticatory muscles (motor fibres) and 
impairment of taste (lingualis to ant. % of tongue). 

6. Abducens. Eyeball cannot be turned outward. 

7. Facialis. Immobility of the muscles of expression of one 
side of the face; eye cannot be closed, the face is drawn to the 
opposite side, dribbling of saliva, etc. In lesions proximal to the 
ganglion geniculi, the soft palate on the same side is paralyzed ; if 
lesion is between the ganglion geniculi and the passage of th •• 
chorda tympaai, there are disturbances of taste in the anterior 'i 
of tongue. In central paralysis of the facialis, only the lower 
half of the face is usually paralyzed, the electro muscular con- 
tractility is unchanged and hemiplegia is frequent. The 
prognosis of peripheral facial paralysis is influenced by the electric 
reaction. If the electric reaction is normal, recovery can be 
expected in 2 or 3 w T eeks ; if diminished but not lost, recovery in 
6 w T eeks ; loss of the faradic and galvanic excitability of the nerve 
and loss of the faradic excitability of the muscles [reaction of 
degeneration) , gives an unfavorable prognosis. 

8. Acusticus. Disturbances of hearing (examine with the 
otoscope). 

9. Glossopharyngeus. Loss of taste in the posterior % of 
tongue. 

10. Vagus. Quickening of the pulse and slowing of the 
respiration. 

11. Accessorizes. Paralysis of the sterno-cleido-mastoid and 
trapezius. 

12. Hypoglossus (motor nerve of tongue). Tongue turns toward 
the paralyzed side when protruded. 



PARALYSIS OF THE SPINAL NERVES. 

Plexus Brachialis. Paralysis of the deltoid, biceps, brachialis 
anticus, supinator longus and infraspinatus {paralysis of Erb) 
muscles. 

Nervus Medianus. Pronation and flexion of the hand, flexion 
and opposition of the thumb and flexion of the finger in the lac 
two phalanges is impossible. 

Nervus Ulnaris. Power is diminished to flex and draw the 
hand to the ulnar side as well as to flpx the last 3 fingers. Little 
finger is immovable. On account of atrophy of the inter ossei. 
the firet phalanges are extended and the second and third phalanges 
are flexed (claw-hand). 

Nervus Radialis (musculo-spiral). Hand hangs in flexion and 
cannot he extended. Fingers are flexed. Thumb cannot be 
extended or abducted. Outstretched arm cannot be supinated, 



163 MANUAL OF CLINICAL DIAGNOSIS. 

but on flexion of the arm the forearm can be supinated by the 
biceps. Lead poisoning is a frequent cause of paralysis of this 
nerve, but the supinator longus is not usually involved. 

Nervus Peroneus. Flexion of the foot is impossible. Tips of 
toes and the outer edge of foot first touch the ground in walking 
(abduction of these parts abolished). 

Nervus libialis. Extension of the foot is lost (patient cannot 
rise on his toes). Abduction of the foot and plantar flexion of 
the toes (claw-like appearance). 

Ataxia. Inability to coordinate with intact muscular 
power certain muscular movements. If patient is directed 
to thread a needle, pick up a pin or make other com- 
plicated movements, the motions are clumsy. Ataxia 
occurs in cerebral and spinal affections (tabes), affections 
of cerebellum and in diseases of the peripheral nerves 
(neuritis) following diphtheria, alcoholism, etc. 

Aphasia. Ataxic (motor) aphasia , the power of coor- 
dinating the movements for articulate speech is partially 
or totally lost. 

Amnesic (sensory) aphasia ; the power of recollecting 
words as aggregate acoustic phenomena is impaired. 

Word dumbness; the inability with intact hearing to 
understand words. This is also called word deafness. 

Paraphasia ; the ability to connect word images and 
corresponding connection is lost. 

Agraphia ; this is the inability to convey thoughts in 
writing. It is present in amnesic aphasia. 

The lesion in aphasia is most frequently found in the 
left hemisphere in the inferior frontal convolution 
(Broca's convolution). 



TESTING THE SENSIBILITY. 

Touch Sense. This signifies (eyes closed) the ability to 
immediately perceive the contact and describe the 
sensation, when the skin is touched with the finger or any 
other object. 

Sense of Locality. Normal individuals locate almost 
accurately the part of the body touched. By the use of 
compasses (sesthesiometer) , the smallest distance maybe 



TESTING THE SENSIBILITY. 169 

found in which both points may be recognized. The 
distance varies in health, and the following measures can 
be used as the healthy standard for comparison: 1. 
Point of tongue, -fa inch. 2. Tip of finger, -fa inch. 3. 
Mucous surface of lips, -fa inch. 4. Tip of nose, | inch. 
5. Chin, i inch. 6. End of big toe, cheek and eyelids, -J 
inch. 7. Bridge of nose, i inch. 8. Heel, i inch. 9. 
Back of hand, | inch. 10. Neck, | inch. 11. Fore-arm, 
If inch. 12. Sternum, If inch. 13. Middle of thigh, 
2| inches. 14. Back, 2f inches. 

Sense of Pressure. This may be tested by placing 
different weights on the extremity. When the sense of 
pressure is greatly disturbed, it can be determined by 
pressure with the finger. 

Sense of Temperature. May be tested with test tubes 
filled with water of different temperatures applied to the 
skin. It may be rapidly tested by breathing and blowing 
on the skin. 

Electro-cutaneous sensibility. Tested with a wire-brush 
electrode and determining the minimum strength of the 
current felt. 

Joint and Muscular sense. This is the ability to deter- 
mine the position of the extremities and their passive 
movements with closed eyes. 

Sensibility to Pain. Tested by sticking with a needle, 
electric current, etc. 

Abnormal Conditions of Sensation. — Anaesthesia 
signifies entire loss of sensibility and depends on inter- 
ruption of sensory conduction. Hypxsthesia, diminished 
sensibility. Hyperesthesia, increase of sensibility. It is 
present in tetanus, hydrophobia, strychnia poisoning, hys- 
teria, etc. Hemianesthesia, loss of sensation in one lateral 
half of body. Present in lesions of the posterior third of 
the internal capsule and in hysteria. Polyxsthesia, is the 
perception of more than one impression although only 
one is made. 

Delayed sensation, is an evidence of imperfect conduction 
of sensations to the brain and is a frequent symptom of 
tabes. Analgesia, is the absence of pain when the skin ig 



170 MANUAL OF CLINICAL DIAGNOSIS. 

pricked with a needle. Occurs with unimpaired tactile 
sense in hysteria and tabes. Perverse sense of temperature 
is present when anything cold is perceived as warm. 
Symptom of Romberg; the patient totters or falls when the 
eyes are closed. It is caused by anaesthesia of the soles of 
the feet and in disturbance of the muscular sense in the 
extremities. It is a frequent symptom of tabes. Pares- 
thesia refers to sensations of tingling, creeping, numbness 
or formication. 

Girdle pain {cincture-feeling), is a sensation of constric- 
tion around the body (usually in the region of the dorsal 
vertebrae), and is present in diseased conditions of the 
posterior columns of the cord. 

Spontaneous Pain. — Headache (cephalagia) maybe 
caused by: 1. Meningitis (pain violent and persistent). 2. 
Syphilis (nocturnal exacerbations). 3. Neurasthenia and 
hysteria. In the latter affections, the pain is limited to a 
small spot along the sagittal suture (clavus hystericus). 
4. Migraine; paroxysms of pains occurring usually on one 
side of the head at irregular periods and attended with 
vaso-motor and gastric disturbances. 5. Intoxication 
from lead, alcohol, mercury and in uraemia. 6. Acute 
infectious diseases. 7. Anaemia. 8. Hyperaemia. 

Nitrite of amyl inhalations diminish anaemic and increase hyper- 
aemic headaches. Infants manifest severe headache by boring of 
the head into the pillow. 

Neuralgia. — The chief symptom of this affection is 
pain ; it is paroxysmal, usually unilateral, follows the 
course and distribution of a nerve, inflammatory symp- 
toms are absent and tender points (puncta dolorosa) can 
be felt along the course of nerve in the intervals of pains 
but more pronounced during the paroxysms. The pain- 
ful points are found where the nerves pass through bony 
canals or penetrate the fasciae of muscles. 

MOTOR SYMPTOMS OF IRRITATION. 

Spasms are involuntary muscular contractions of a 
single muscle or a group of muscles. They may be clonic 
(alternate contraction and relaxation of a *nuscle) or tonic 



MOTOR SYMPTOMS OF IRRITATION*. \1\ 

(rapid recurrence of contractions, so that affected muscle 
appears in a fixed condition). Convulsions arc clonic 
spasms extending over the entire body. 

Clonic-tonic spasms occur in epilepsy, puerperal con- 
vulsions, uraemia, irritation of the cortical centers 
(tumors abscess, etc.), at the onset of acute febrile dis- 
ease, and in children from reflex causes (dentition, intes- 
tinal worms, indigestion, etc.) 

Tonic spasms occur in: tetany and tetanus. In tetany , 
"Trousseau's sign' 7 is characteristic, i. e., energetic con- 
tractions can be excited by pressure of the arm in the 
regions of the median nerve and brachial artery. Mechan- 
ical and electrical excitability of the peripheral nerves 
and muscles also exist. Temperature is normal. In 
tetanus, there is an elevation of temperature. The disease 
is as a rule fatal. 

Varieties of Local Spasm.— Tonic spasm of the internal rectus is 
recognized by strabismus. Nystagmus is a bilateral affection fre- 
quently occurring in multiple sclerosis and is particularly marked 
when the patient looks at remote objects. It is due to clonic 
spasm of the muscles of the eyeballs. Trismus is a tonic spasm of 
the masticatory muscles (lock-jaw) and occurs in tetanus. 

Facial spasm (convulsive tic) affects the muscles of the face. 
Partial spasm of the eyelids causes constant winking (nictitating 
spasm) , if the entire orbicularis palpebrarum is affected the eyes 
may be firmly closed (blepharospasm). Spasm of the Oesophagus 
frequently occurs in hysteria {globus hystericus). 

Laryngismus stridulus, is caused by spasm of the glottis and is 
frequent in children. Hiccough, is spasm of the diaphragm (sin- 
gultus). Writer 1 s cramp and similar professional neuroses consist 
of spasmodic contraction of definite muscle-groups when certain 
movements are made. 

Thomsen's disease is characterized hy the occurrence of 
spasmodic rigidity of voluntary muscles, when they are 
called into action after intervals of rest (intentional 
spasms). 

Contracture is the permanent contraction of a muscle, 
which fixes the limb either in a flexed or extended posi- 
tion. Contracture of the muscles occurs in organic 
diseases of the spinal cord (especially if the lateral 
columns are implicated) and is associated with an increase 
of the spinal reflexes. 



172 MANUAL OF CLINICAL DIAGNOSIS. 

Tremor consists of slight contractions of bundles of 
muscular fibres. It is physiological after physical and 
psychical exertion. Tremor may be permanent and still 
physiological in old people (tremor senilis). Tremor alco- 
holicus occurs particularly in the extremities and tongue. 
In morbus Basedowii (exophthalmic goitre) a fine tremor 
also occurs. The tremor of paralysis agitans is controlled 
by active exertion and ceases during sleep. The thumb 
closes on the fingers as in " rolling pills." 

Intentional tremor is observed in voluntary movement 
of the muscles and is an important symptom of multiple 
sclerosis. It is also present in tremor mercurialis. Trem- 
bling of the eyes (nystagmus) is present in multiple 
sclerosis, hysteria and in affections of the eye. 

Fibrillary contractions of muscular bundles are seen in 
atrophic paralyses, particularly in progressive muscular 
atrophy. 

Choreic movements are quick, involuntary and incoordi- 
nate movements, which prevent and interfere with 
voluntary motion. They cease during sleep and are 
pathognomonic of chorea. Choreic movements on one 
side of the body (hemichorea) can precede or follow hemi- 
plegia (lesion in the posterior part of internal capsule). 

Athetosis. The characteristic movements of this affec- 
tion are most pronounced in the hand and fingers. The 
fingers are never at rest and they are constantly flexed, 
extended or intertwined. Athetosis may be idiopathic 
but more frequently it is symptomatic of cerebral infantile 
paralysis. Hemiathetosis has the same significance as 
hemichorea. 

Catalepsy is characterized by a peculiar rigidity of the 
muscles (flexibilitas cerea) which enables the physician to 
put the limbs in any posture where they will remain fixed 
until the position is again changed. Catalepsy is most 
frequent in hysteria. Also present in meningitis and in 
certain psychoses (melancholia attonita). 



REFLEXES. 173 



EEFLEXES. 

Reflexes are of two kinds, superficial (skin) and deep 
(tendon). The former are excited by irritating the skin, 
the latter by exciting the tendons or fasciae of muscles. 

£kin Reflexes. — 1. Plantar reflex. This is excited by tickling 
the sole of the foot. It causes a dorsal flexion of the foot and when 
the irritation is strong, the leg is drawn up. 

2. Cremaster reflex. Irritating the inner side of the thigh will 
cause retraction of the testicle. 

3. Reflex of the abdominal walls. Irritating the skin of the abdo- 
men causes contraction of the abdominal muscles. Irritating the 
skin of the scapular (scapular reflex) and gluteal (gluteal reflex) 
regions causes contraction of the corresponding muscles. 

Skin reflexes are absent or diminished when the reflex circuit 
(centripetal nerve, anterior horn of spinal cord and motor nerve) 
is broken. This occurs in affections of the peripheral nerves and 
spinal cord. 

Tendon Reflexes. — 1. Patellar reflex (knee-jerk) is obtained by 
percussing the patellar tendon while the leg is crossed and com- 
pletely relaxed; this is followed by contraction of the quadriceps 
and the leg is extended. 2. Tendo Achillis reflex: percussing 
this tendon causes contraction of the calf muscles. 3. Foot clonus; 
if the leg is slightly bent upon the thigh and the foot quickly 
flexed rythmical contractions of the calf muscles will ensue. 
Tendon reflexes in the upper extremities rarely occur in health. 

In health the knee-jerk is almost constant (about 2% of all 
adults fail to show the knee-jerk), the tendo Achillis reflex is fre- 
quent, while a persistent foot clonus never occurs. Tendon 
reflexes are absent when the reflex circuit is broken. The Reflex 
circuit is formed by the nerves (sensory) going to the spinal cord 
from the muscle or tendon, the motor nerves going to the muscles 
and by that portion of the spinal cord connecting both. The ten- 
don reflexes are absent in peripheral paralyses, tabes dorsalis and 
poliomyelitis. Increased reflexes occur w T hen the inhibitory centers 
are diseased or their fibres interrupted in their course from the 
brain through the pyramidal tracts of the spinal cord. 

Paradox contraction (Westphal) occurs in multiple sclerosis and 
paralysis agitans. It consists of a contraction of the tibialis anticus 
with prominence of its tendon when the foot is firmly and quickly 
flexed, the foot remaining in this position for a few minutes after 
it is let go. 

Reflex Functions. — 1. Pupillary reflex. The pupil is supplied by 
the oculomotorius for the sphincter and the sympathetic for the 
dilator pupillce. Irritation of the former nerve causes contraction 
(myosis), of the latter, dilatation of the pupil (mydriasis). The cen- 



174 MANUAL OF CLINICAL DIAGNOSIS. 

ter for the pnpil reflex (centrum cilio- spin ale) is situated in the 
lower cervical region. In tabes, the pnpils contract to accommo- 
dation but not to light {Argyle Robertson symptom.) The pupils 
are also contracted (myosis spinalis) and irregular in tabes and 
paretic dementia. 

2. Disturbances in the passing of the urine and faeces as well as 
the sexual reflex occur in lesions involving the lumbar region of 
the spinal cord. 

Mucous membrane reflexes. 1. Conjunctival: closing the eyes 
when eyeball is touched. 2. Pharyngeal: nausea or vomiting 
when the pharynx is touched. 3. Coughing when the larynx or 
the air-passages are irritated. 4. Sneezing when the nasal mucous* 
membrane is irritated. 



EXAMINATION" OF THE NERVES AND 
MUSCLES BY ELECTRICITY. 

The faradic and galvanic currents are employed in 
medical diagnosis. Static electricity (Franklinism) is 
sometimes used as a therapeutical agent. 

The faradic current is produced by the magnetizing and 
demagnetizing of a bar of soft iron by means of a galvanic 
current. The strength of the faradic current is regulated 
by sliding one coil over the other as indicated by a grad- 
uated scale. The strength of the galvanic current is regu- 
lated by the number of elements used or by means of a 
rheostat Electricity is applied to the body by means of 
electrodes. 

Electro-motive Force. This is the work which a definite 
quantity of electricity can do and is influenced by the 
resistance offered to the current. The strength of electric 
currents is determined by Ohm's law : The strength or 
intensity (7) of the current is always proportionate to the 
electro-motive force {E) divided by the resistance. This is 
mathematically represented by the following formula : 
I=|. An ampere is the intensity of the current (I) gener- 
ated by the electro-motive force (E) of 1 volt in an electric 
current of resistance (R) of 1 ohm. One volt equals T 9 ^ 
the electro-motive force of a Daniell element; one ohm 
equals a column of mercury 106 cm. long, and 1 square 
millimetre in section (1.06 Siemen's unit). The resistance 



ELBCTRO-DIA GNOSIS. 175 

of the human body is diminished by saturation of and 
pressure upon the electrodes. The relative resistance of 
the tissues is represented by the following figures (100 
taken as the maximum); eye, 4; muscle, 6; nerve, 10; 
fat, 75; bone and skin, 100. The epidermis when dry, is 
practically a non-conductor of electric currents. 

Measurement. — The unit of current strength adopted 
for medical purposes is the milliampere which is the one 
millionth part of an ampere. Galvanometers now 
employed are divided into milliamperes and from the 
deflections of a needle, the number of milliamperes can be 
noted. 

The Poles of the Galvanic current. — The galvanic 
current is generated by the contact of dissimilar metals 
exposed to chemical action. The simplest form of a gal- 
vanic cell, consists of a plate of zinc and one of carbon 
immersed in a vessel containing dilute sulphuric acid. 
The wire connected with the zinc is the negative pole or 
Kathode (Ka) while the wire connected with the carbon 
is the positive pole or Anode (An). 

One pole is distinguished from the other as follows : With a weak 
current place both electrodes on either cheek ; a peculiar taste is 
experienced at the anode electrode. If the wires are dipped in 
water, bubbles of hydrogen accumulate about the kathode. If the 
wires are placed on moistened blue litmus paper the latter will 
become red at the anode. If the wires are immersed in a solution 
of iodide of potash containing starch, a blue color, due to free 
iodine and starch, appears at the anode. German authors employ 
the symbols S, for closing (Schliessung), O, for opening (Oeffnung), 
and Z, for contraction (Zuckung). 

Electro - Diagnosis. — The indifferent electrode 
(usually large) is placed on the sternum, whereas the 
different or active electrode (usually small) is placed on 
the nerve or muscle to be examined. A muscle may be 
made to contract directly by placing the electrode on the 
muscle or indirectly by placing it on the nerve (motor point). 
Stimulation of the motor points indirectly excite the mus- 
cles to contraction, each muscle possessing a motor point 
which has been empirically established (Figs. 19-23). 




bo 



•o -o ^ aS 
• .n * a.- 



S Sc 




(176) 









Nervus crura! 


is. 










Nervus tibialis: 






7i 

9 


*2 
o 

c 
~ n 


6 


•S 5 *• 
igS S 


13 

3 


X 

3 ^ 

«n 3 

"J 


.5 
) 

3 • 
Pg 


■ c 


"3 


3 

,3 


•3 s 


o 
o 


X 


% 


S 


2 S 


*5 


fH 


<. 


s 


S 


s 


*£ 






Nervus obturatonus. 



Nervus peroneus. 



Nervus tibialis. 







ULL 




177) 



178 



MANUAL OF CLINICAL DIAGNOSIS. 



With the faradic current muscular contractions occur 
by direct or indirect irritation. The weakest current 
necessary to produce muscular contraction is noted by 
the position of the coils as indicated by a scale in 
millimetres. 



Region of central 
convolutions. 

Region of third 
frontal convolu- 
tion and island 
of Reil. 

M. temporalis. 

{U. branch. 
M.branch. 
Trunk. 
L. branch. 
N, auricular post. 
Mtsplenius capitis. 

M sternocleido- 
mastoid. 

N. accessor Wii- 

lisii. 

M- cucullaris ; 

N. dors, scapulae. 

N. axillaris. 

N. thoracic, long. 

(M. serratus aati- 

cas, ) 

N. phrenicus. 
Plexus brachialis. 




Supraclavicular point of £rb (Mm. deltoldeus, biceps, 
supinator longus et brevis, infraspinatus et 

Fig. 23. 



H. frontalis. 

M. corrug. super* 
cil. 

M. orbicular, pal* 
Debr> 

M» levator labii 
super* alaeque 
nasi, 

.Mm^zygomaticii 

M. orbicular, oris. 

M, masseter, 

M» levator menti. 

M. quadrat* mem. 

ti. 
M v triangul.ment?, 

N. : hypoglossus, 

Platysma 

myoides, 

M«scles of hyold 

bone» 
j^ . 

■N, thoracicus _ art' 
\terior (M.pecto.- 
> ral major,) 

brachial, intern. [antTcusj, 
subscapularis). 



With the galvanic current, the Kathode is placed on the 
muscle or nerve to be examined. The strength of current 
is gradually increased until a contraction occurs at the 
closing of the current (Kathodal closing contraction, KCC.) 
The intensity of the current necessary to produce contrac- 
tion is indicated by the galvanometer or by the number 
of elements used. 

KCC occurs normally in superficial motor nerves with a current 
intensity of 1-3 milliamperes (MA). 

By means of the polarity changer or commutator, without 
changing the position of the electrodes the kathode may be con- 
verted into the anode and vice versa. 



BORMULA OF NORMAL POLAR ACTION. 1*9 

Formula of Normal Polar Action. 

1. Weak current: Kathodal closing contraction (KCC). 

2. Medium current : Strong Kathodal closing contraction (KCC), 
moderate anodal closing contraction (ACC) and moderate anodal 
opening contraction (A 0(7). 

3. Strong current: Tetanic Kathodal closing contraction (Te 
KCC), strong anodal closing contraction (ACC), strong anodal 
opening contraction (AOC) and Kathodal opening contraction 
(KOC). 

This formula only holds good when the muscles are 
indirectly stimulated with the galvanic current. In direct 
stimulation of the muscles there are only closing contrac- 
tions, and ACC may be equal to KCC. 

Quantitative changes of electrical irritability refer to the 
energy and amplitude of contractions. The electrical 
irritability is increased in tetan}' ; diminished, in paralysis 
resulting in simple atrophy as in apoplexy and in bulbar 
and spinal paralyses when the trophic ganglia are intact. 

Increased Electric Excitability occurs when a weak current will 
produce energetic contractions and it is diminished when a strong 
current is necessary to excite muscular contraction. In unilateral 
paralysis the healthy side may be used as a basis of comparison. 

Qualitative changes refer to abnormal polar reaction. If 
a motor nerve is cut off from its trophic centre or if the 
trophic centre is diseased, paralysis occurs and the nerve 
degenerates (degenerative atrophy), the degeneration 
extending to the muscle supplied by it. There is also 
diminished electric irritability of the nerve for the far- 
adic and galvanic currents and after 8 to 14 days the 
irritability is entirely lost. Direct faradic irritability of 
the muscle is also entirely lost. After 2 weeks direct 
galvanic irritability of the muscle is increased and contrac- 
tions occur even with mild currents ; the contractions are 
not short and quick as in health, but long and slow. 
ACC with the same current, occurs as soon or sooner than 
KCC; KOC may be obtained with weaker currents than 
the AOC. The foregoing reaction is the reaction of degen- 
eration (RD). In severe cases, showing RD, the galvanic 
irritability is finally lost after 4 to 8 weeks. 

In curable cases showing RD, the voluntary power of the affected 
muscle is restored sooner than^ the electric irritability. The 
reaction of degeneration is present in all peripheral lesions of the 



180 MANUAL OF CLINICAL DIAGNOSIS. 

motor nerves whether of traumatic, rheumatic, toxic or diphtheritic 
origin ; also in diseases of the gray matter of the anterior horns of 
spinal cord and gray nuclei of medulla. The RD is absent in all 
cerebral and spinal paralyses, the cause of which is central from 
the trophic centre. 

The presence or absence of the RD is of value in prognosis. If 
present, it indicates either that the atrophy of the affected muscles 
is incurable or that at least 2-3 months will be necessary for their 
restoration. If absent, it indicates the absence of gross anatomical 
lesions and cure may result in a few weeks. 

Partial Reaction of Degeneration. — In this condition the 
nerve retains its faradic and galvanic irritability and the 
muscle its faradic irritability, but the direct galvanic 
irritability of the muscle is increased, the normal formula 
of polar action is altered and the contractions are slow 
and long. This reaction shows anatomical changes in the 
muscle but not in the nerve. 



INSTANTANEOUS DIAGNOSIS IN NER- 
VOUS DISEASES (Erb). 

Tabes dorsalis is, as a rule, easy to diagnose; although, even at 
the present time, it is mistaken for myelitis, spastic paralysis, 
neuritis, etc. The diagnosis of this affection can at once be made, 
when the patient enters the room with an ataxic gait, when he 
complains of lancinating pains, double vision, weakness, tired feeling, 
and paresthesia of the legs, vesical and genital weakness. An 
examination of the eyes will show contraction of the pupils, and a 
failure of the latter to respond to light. The patient will totter 
with closed eyes, and the knee-jerk is abolished. Parkinson's dis- 
ease, or paralysis agitans, is also capable of immediate diagnosis. 
The marked inclination of the body forwards, the attitude of the 
fingers, as if employed in holding trie pen, the immobility of facial 
expression, the peculiar gait, as if the patient were about to tumble 
forward, all give, when combined with the peculiar tremor, a charac- 
teristic picture. The tremor is not always essential in making the 
diagnosis, for there are cases in which this symptom is permanently 
absent. Tetany. — A young man or woman is troubled with par- 
oxysms of tonic muscular spasms in the hands or legs. If, now, 
with the end of the finder, or a lead pencil, a vertical stroke is 
made running from the temporal region to the lower jaw, and a 
rapid contraction of the facial group of muscles occurs, the diag- 
nosis of tetany can with certainty be made. The diagnosis is 
confirmed when, after the nerve trunks of the arm are struck, 
violent contractions of the muscles ensue ; or when, by application 
of the galvanic current to the nerve trunk, kathodal closure 
tetanus and anodal closure tetanus are rapidly developed with 



DIAGNOSIS IN NERVOUS DISEASES. 181 

even weak currents, the muscles showing increased irritability 
Thomsen's disease. — A young person complains with reference to 
a weakness and stiffness of intended movements. You ask the 
patient to grasp your hand, and he will be unable, when told, to 
immediately loosen his grasp. Now strike the exposed deltoid 
muscle, or the biceps, and an energetic contraction, lasting many 
seconds, occurs. This is Thomsen's disease, or myotonia congenita. 
If the symptomatic picture is to be completed, u^e the faradic and 
galvanic currents. The nerves show normal irritability; the 
muscles, on the contrary, are irritable and qualitatively changed 
(myotonic reaction). Besides the tendency of the muscles to tonic 
spasm during attempts at voluntary movement, and the myotonic 
reaction, absolutely nothing else abnormal is found, other than 
the disproportion existing between the well-developed muscles and 
the weakness of the patient. Basedow's disease (exophthalmic 
goitre) : The well-known symptoms, exophthalmos, pulsating struma, 
and cardiac palpitations, are so characteristic that the affection is 
at once recognized. Cases exist, however, where the exophthalmos 
is absent, or the thyroid gland not enlarged. In such cases the 
cardiac palpitations and acceleration of the pulse (120 to 160 beats 
per minute) without manifest cardiac change, auscultation of the 
pulsating struma, the feeling of weakness and tremor, the tendency 
to sweating, sleeplessness, and diminished electrical conduction 
resistance of the skin, are symptoms of value in undeveloped forms 
of Basedow's disease. 

Dystrophia Muscularis Progressiva.— The patient is a child with 
weakness of the legs, clumsiness in walking and difficulty in rising 
from the recumbent or sitting position ; you ask to have the clothes 
removed and proceed to examine the patient more carefully. A 
waddling movement is noticeable, together with lordosis in the 
lumbar region. The thighs are characteristically attenuated when 
contrasted with the muscles of the calf, which are increased in 
size. When the child is raised from the arms, the shoulders 
ascend to the ears and the head sinks between the shoulders, so 
that difficulty is experienced in lifting it in this manner, so readily 
accomplished in healthy children. The failure is attributed to 
the inability to fix the shoulders below. The individual forms of 
this disease can at once be recognized. The pseudohypertrophic 
form, by the increase in size of the muscles, which is not propor- 
tionate to their motor power; the juvenile, by the more severe 
involvement of the upper half of the body, the pronounced atrophy 
and relatively late development of the affection ; the infantile, by 
the early invasion of the face. Infantile paralysis {poliomyelitis 
anterior acuta). In these cases the child presents an atrophic 
paralysis of one or more extremities, whereas individual muscles, 
or muscle groups, are exempt. The sphircters are intact, and the 
affection has occurred suddenly. Sensation is not involved, and 
the tendon reflexes in the affected muscle regions are absent. The 
examination is completed when the reaction of degeneration is 
determined. Multiple sclerosis: Intentional tremor of the hand, 
shaking of the entire body when an attempt is made to rise or 



182 MANUAL OF CLINICAL DIAGNOSIS. 

walk, scanning speech, nystagmus, spastic paresis of the legs, and 
history of headache, vertigo, vesical weakness, etc., constitute the 
characteristic symptoms of this disease. ^ Progressive bulbar 
paralysis : Difficulty in articulation, nasal voice, thin lips and with 
difficulty moved, the inability to protrude an atrophic tongue in 
which fibrillary contractions are observed, difficulty in swallowing, 
etc. Amyotrophic lateral sclerosis: This affection shows a com- 
bination of atrophic paresis with increased tendon reflexes in the 
upper, and spastic paresis in the lower extremities. — Deutsche Med- 
icin. Wochenschrift, October 17, 1889. 



MEDICAL OPHTHALMOLOGY. 

Ophthalmic Examination of the eye is of great importance in 
medical diagnosis. In the following affections the ophthalmoscope 
establishes or corroborates a diagnosis. 

Aortic Insufficiency. — An alternate flushing and pallor of the 
optic disc analogous to the capillary pulse, and pulsation of the 
retinal vessels is observed. 

Congenital Heart Lesions. — The retinal vessels are distended. 

Leucsmia — Diffuse retinitis with haemorrhages and yellow color 
of the eye ground. 

Pernicious Anaemia. — (Edema of the retina with haemorrhages. 

Haemorrhage. — Loss of blood may cause impaired vision from 
transient anaemia of the retina or cerebral centres. Ophthalmo- 
scopic examination not diagnostic. 

Bright's Disease. — (Edema of the disc and surrounding retina 
with irregular white splotches, and striated haemorrhages. About 
23% of patients with renal diseases have disorders of vision at some 
period of the disease. The eye lesion may be the first symptom 
of the renal affection. 

Tuberculosis. — Usually in children tubercles are deposited in 
the choroid, intra-ocular end of the optic nerve, retina or iris. 
Their favorite seat is the macular region and its vicinity. The 
deposit of tubercles may precede other symptoms. According to 
Cohnheim in all cases of acute miliary tuberculosis, tubercles are to 
be found in the choroid; although this view is vigorously disputed 
by other observers. 

Diabetes Mellitus. — Diabetic neuroretinitis and atrophy. The 
retinal changes resemble those due to albuminuria. Cataract is 
also found and grape sugar may be detected in such lenses by 
chemical examination. 

Tabes Dorsalis. — Atrophy of the optic nerve is an early and 
frequent symptom, and may precede by many years, the develop- 
ment of spinal symptoms. In the early stages, the discs are of a 
dull, reddish-gray tint, w T hich gradually becomes paler, and at last 
white. Later £he nerves assume a greenish tint, the surface of 



MEDICAL OPHTHALMOLOGY. 183 

the disc becomes excavated, and the retinal blood-vessels shrink. 
Atrophy of the optic nerve is also observed in disseminated sclerosis 
and paralytic dementia. 

In tabes the field of vision is narrowed and the sense of color is 
disturbed ; green being lost first, then red, and finally, yellow and 
blue. 

Increased intracranial pressure —{Turn on, meningitis, hydro- 
cephalus). The optic nerve is swollen and projects above the level 
of the surrounding retina ; the margin of the disc is either obscured 
or entirely lost ;the arteries are small, the veins large and tortuous 
(choked disc). Ihese changes usually occur on both sides alike, 
and of equal intensity. Like changes in the fundus occur in about 
J of all tumors of the brain. 

Exophthalmic Goitre. — Dilatation and tortuosity of the retinal 
veins. Functions of the retina unimpaired. Spontaneous pulsa- 
tion of the retinal vessels has been observed. Protrusion of the 
eye ball is often combined with a want of agreement between the 
movement of the lid and the raising or lowering of the eye 
{symptom of Graefe), 

Syphilis. — (Syphilitic retinitis). Retina is covered by a gray 
film, and in the macular region numerous irregularly placed 
punctate sj-ots are present. 

Lead intoxication may be followed by optic neuritis with consec- 
utive optic nerve atrophy. In quinine poisoning, there is pallor of 
the optic disc, and narrowing of the field ot vision. Alcohol and 
tobacco intoxication also lead to atrophy of the optic nerve. 



CHAPTER XTIL 

PARASITES. 

ANIMAL PARASITES. 

The diagnosis of animal parasites is only possible in many cases 
after careful examination of fresh fsecal matter with the micro- 
scope. The amozba and infusoria lose their activity soon after 
evacuation of the stool, and for this reason Eichhorst recommends 
the removal of the mucus and faeces from the rectum by means of 
a glass tube, and direct transference of the same to the object 
glass. The microscope will also aid in the diagnosis of eggs of 
the intestinal parasites. 

Animal parasites belong either to the Protozoa or to the worms. 
The protozoa are divided into rhizpoda and infusoria, and the 
worms into flat (platodes) and round worms (nematodes). The 
following parasites are of practical importance: I. Protozoa; a. 
Rhizpoda : amoeba coli. b. Infusoria : 1 . Cercomonas intestinalis. 
2. Trichomonas intestinalis. 3. Balantidium coli. 

IL Worms. — a. Flat worms (platodes)* 

1. Taenia solium. 

2. Taenia saginata or taenia mediocanellata, 

3. Bothriocephalus latus. 

4. Taenia echinococcus. 

b. Bound worms (nematodes*) 

1. Ascaris lumbricoides. 

2. Oxyuris vermicularis. 

3. Trichocephalus dispar. 

4. Anchylostomum duodenal©. 
6. Trichina spiralis. 

6. Filaria sanguinis. 

Only finding in the stools the parasites, segments of the tape- 
worms or eggs by the microscope can be considered as diagnostic. 

Protozoa. Amoeba coli, A round granular structure with a 
nucleus and several vacuoles. 

Cercomonas intestinalis. This parasite is pear-shaped with ciliated 
extremities and is yV~A °* an * ncn l° n g- 

Trichomonas intestinalis. Almond-shaped with ciliated extremi* 
ties and is ^~A of an inch long. 

(184) 



FLAT WORMS. 



185 



BalantkUum cch rear-shaped, ciliated and with an inverted 
mouth. It is about * 4 of an inch long. 

Tape or Flat Worms (platodes).— They are acquired 
by the ingestion of raw or insufficiently cooked meat con- 
taining the eggs. Taenia solium is acquired by eating 
ill-cooked pork. to 

Taenia saginata is derived from beef and the Bothrio- 
cephalus latus, from fish. The three species can be diag- 
nosed by voiding of the segments (proglottides). The 
bothriocephakis is the most easily removed by medication, 
whereas the T. saginata requires the most active treatment 



Fig. 25. 




?- g> It' J 8en r a solium - a. head, b. egg, c. segment, 
tig. 25. Taenia saginata. a. head, b. egg, c. segment. 

i i!?"- .\i a ' £ g of the ox y uris vermicularis. b. egg of ascaris 
lumbncoides. Fig. 27. Muscle trichina. 

The tapeworms are composed of a head (scolex) and segments 
(Prof/hmdes) The eggs come from the matured segments (herma- 
phrodite), and, when taken into the stomach of an animal the 



186 MANUAL OF CLINICAL DIAGNOSIS. 

capsules are dissolve! and the embryo is dislodged. It then 
reaches the tissues and develops into a cysticercus. This cysticer- 
cus when contained in the food ingested by man develops- into a 
new tapeworm. The method of examining a segment is to press 
it slightly between two object glasses and examine with trans- 
mitted light. 

Taenia solium. This (tapeworm) is 1-3 meters (yards) 
long. The head is about the size of a pin's head, contain- 
ing 4 suckers, and is prolongated into a proboscis (rostel- 
htm) surrounded by a double row of hooks (20-30). 
The matured proglottides have the sexual opening at the 
side somewhat behind the middle, They have a uterus 
w r ith 7-10 thick lateral branches, which subdivide. The 
eggs are round or oval with a striped shell containing an 
embryo with 6 hooks. This cystic condition of the taenia 
(cysticercus cellulosse) may be found under the skin, in the 
brain, eye, and muscles, causing severe disturbances. 

Taenia saginata. (7-8 meters long). Larger than the 
former. The head has 4 suckers without rostellum or 
hooks. Sexual openings are on the sides of the proglottides. 
The uterus has 20-30 lateral branches, which are finer 
than those of the T. solium. The eggs are like the latter 
but larger. The cysticercus does not develop in the tissues 
of man. 

Bothriocephalic latus (4-5 meters long.) Lancet-shaped 
head with two lateral grooves. Matured proglottides are 
broader than long and genital apertures are found in the 
median line. 

The uterus is arranged in the form of a rosette around 
the sexual openings. 

Taenia echinococcus. Found in the dog. It has a head 
(scolex) with hooklets (30-40), suckers and 3 segments, of 
which the last one alone is matured. Only the cystic form 
or hydatid is found in man, which he acquires by eggs 
introduced into the alimentary canal. When the embryo 
migrates from the intestine to some other organ (liver, 
spleen, kidneys, lungs, etc.), it is transformed into a cyst 
incapable of active motion. 

The hydatid cyst consists of an external elastic cuticle, and an 
internal lining, the parenchymatous layer. An echinococcus cyst 
may be simple (unilocular) . filled with daughter cysts, or it may 
contain a large number of minute cavities filled with a gelatinous 
substance and with concentrically arranged walls {multilocular) . 



BOUND WORMS. 187 

The nature of an echinococcus cyst can only be determined by 
puncture and examination of the withdrawn fluid. The fluid of a 
cyst is usually clear, neutral or alkaline, with a specific gravity of 
1*003-1013. It contains little or no albumen, but large quantities of 
sodium chloride, frequently grape sugar and succinic acid. The 
latter is detected as follows: Evaporate the fluid and add hydro- 
chloric acid; shake with ether and allow the ether to evaporate. 
If succinic acid is present it remains as a crystalline masd. The 
latter when dissolved in water will give with chloride of iron, a 
rust-colored gelatinous precipitate of succinate of iron. Heated in 
a test-tube irritating fumes of the succinic acid are given off, caus- 
ing cough. The microscopic demonstration of the echinococcus 
is based on the presence of scolices or their hooklets, or the cystic 
membrane. The scolices are easily recognized by the presence of 
suckers and hooklets. The hooklets, are small and transparent 
and a magnifying power of 500 diameters is necessary for their 
detection. 

In the case of acephalo- cysts, i. e., non-propagating cysts, exam- 
ination of the membranes is necessary in diagnosis. The mem- 
branes have a characteristic striped appearance. 

Round Worms. — Ascaris Lumbricoides (round worm). 
Its habitat is in the small intestine, but it may pass to 
other parts of the body. It resembles the ground-worm in 
shape. The male is smaller (4-6 inches) than the female. 
When the worm does not pass off with the faeces, then 
examination must be made for the eggs, which are expelled 
in large quantities. They have a thick, concentrically 
striped shell, upon which lies a thick, tuberculated albu- 
minous cover. These worms are generally innocuous. 

Oxyuris vermicularis (thread worm). Its habitat is 
chiefly the rectum. When passed in a living condition, it 
exhibits a lively motion. These worms cause intense 
itching in the region of the anus. The female is longer 
(-£ inch) than the male (i~i inch). The female has a 
finely pointed tail-end, whereas the male fmore rare) 
has a blunt tail-end curved in the shape of a hook. 
The diagnosis is made from the constant passage of the 
worms with the stool, or by searching for the eggs which 
are oval and possess a thin shell. 

Tricho-cephalus dispar {whip-worm). It inhabits the caecum, 
although rarely in large numbers. It is 1K~ 2 inches long, and has 
a thread-like head extremity, w T hile the tail-end is considerably 
thicker. The egus (necessary for diagnosis) are about the size of 
those of the oxyuris and shaped li ke a lemon. 



188 MANUAL OF CLINICAL DIAGNOSIS. 

Anchylostomum duodenale (hook-worm). It inhabits the 
email intestine, where it hooks itself fast and sucks blood, 
causing pronounced anaemia. This worm is found in tun- 
nel workmen, brickmakers and miners. In persistent 
anaemia of these individuals the worm should be sought 
for after the administration of an anthelmintic. 

\ The anchylostomum is somewhat larger then the oxyuris and its 
mouth is armed with three pairs of hooked teeth. The eggs are 
about the size of those of the oxyuris and are usually found" in the 
stages of vitelline segmentation. The eggs arj developed a few 
days after the passage of the larvae from the intestines. If the eggs 
are not recognized, the faeces are allowed to stand in a warm place 
for 2 or 3 days and then reexamined with the microscope. 

Trichina spiralis. Found in the human body as muscle 
and intestinal trichinx. It enters the intestine by means 
of trichinosed pork. 

When the pork containing the live encysted trichinae reaches the 
stomach the capsules are dissolved and the trichinae set free. 
They mature in the intestine in about 2*4. days, and bring forth 
after 5-7 days young trichinae which migrate through the intestinal 
walls and reach the striated muscles where they become encapsuled. 
A single worm may bring forth 100\)-1300 young. The male trichina 
is xV inch long, the female \ inch long. 1 richinosis is attended 
w T ith various symptoms. When trichinous flesh is first ingested, 
there are symptoms of gastric and intestinal catarrh. 

Muscular invasion is attended with fever, oedema, partial paral- 
yses, muscular abscesses and pain. The symptoms reach their 
height in the 4th or 5th w r eek. The violence and gravity of the 
symptoms depend generally on the number of trichinae which have 
entered the muscles. The trichinae are most abundant in the dia- 
phragm, intercostal, cervical and laryngeal muscles. They are 
less often found in the muscles of the extremities where they are 
usually crowded together at the attachment of the muscle to its 
tendon. 

The removal of a piece of musclefor microscopical examination 
is often necessary for diagnosis during life. An accurate and sim- 
ple method for determining the presence of trichinae in pork is the 
following: The suspected piece of meat is put into a mixture of 
pepsin and dilute hydrochloric acid and allowed to remain in a 
conical-shaped glass at the body temperature. In the latter after 
digestion the free trichinae are deposited and may be removed by 
means of a pipette for microscopical examination. 

Filaria sanguinis hominis. Indigenous only within the 
tropics (Egypt. Brazil, India, etc.). In its sexually mature 
form it is a filiform worm (8-10 ctm. long). It inhabits the 
lymphatics especially those of the scrotum and lower 



ANIMAL PARASITES. 189 

limbs. It obstructs the lymph-vessels and causes inflam- 
mations which terminate in elephantiasis of the tissues 
with oedema and lymphangiectasis. 

The embryos pass from the lymphatics into the bloo'l and cause 
hematuria and chyluria. The embryos may be excreted with the 
urine. An examination of the blood with the microscope shows 
the presence of embryos which appear as little worms r ^ inch 
long and as broad as the diameter of a red blood corpuscle. They 
are found in the blood at limes only during the night hours, hence 
an examination at this time may be necessary. They may remain 
for months or years in the body without creating manifest disturb- 
ances. 



EXTERNAL PARASITES. 

The external parasites may be divided into animal and 
vegetable. 



ANIMAL PARASITES. 

Sarcoptes hominis (acarus scabiei). — The itch mite bores 
its way obliquely through the horny layer of the skin 
until it reaches the rete mucosum in the neighborhood of 
the papilla. In this way it forms furrows (cuniculi) at 
the ends of which the insect is found. In its course it 
leaves behind excreta (yellow, brown or black grains and 
lumps). The female lays its eggs in the furrow and as 
these are hatched (8-14 days), the young mites may be 
seen in all stages of development. 

The itch mite selects the soft skin between the fingers, flexor 
surfaces of the joints and parts pressed upon by tight portions of 
clothing. In males, the penis and lower part of the abdomen are 
usually invaded. The parasite is secured by passing a needle 
along the furrow toward the papule ; on tearing op m the furrow, 
the acarus usually adheres to the point of the needle. The best 
specimen is obtained by snipping by means of curved scissors, a 
piece of the skin containing the furrow. 

Acarus folliculorum. — Occurs in about 10 per cent, of all healthy 
adults in the sebaceous and hair follicles of the face. 

Pediculus capitis (head louse). — Inhabits the hairy scalp. It 
fastens its eggs to the hairs by means of a chitinous covering and 
they may be seen as grayish oval bodies. The young louse 
emerges in about 8 days. 



190 MANUAL OF CLINICAL DIAGNOSIS. 

Pediculus pubis (crab lmse). — Smaller than the former and 
invades the hairy parts of the genitals. 

Pediculus vestimentorum (body louse). — Inhabits the underclothing 
and passes to the surface of the body in order to feed. 

Pulex irritans (flea). — This draws blood from the skin like the 
pediculi. A small punctiform haemorrhage surrounded by a red- 
dened areola is found at the point attacked. 

Dracunculus rnedinensis (Guinea worm) — Found in those residing 
in the tropics. Occupies the subcutaneous tissue about the ankle. 
The usual method of securing the parasite is by fixing an exposed 
portion to a short rod and twisting it a little every day, until the 
entire worm is withdrawn without breaking. 

Chigoe (pulex penetrans). — The sand-flea is principally confined 
to the West Indies and attacks the bare feet of the natives. 



VEGETABLE PARASITES. 

Mould and yeast fungi, like bacteria, draw their nutri- 
ment from organic carbon compounds. The mould fungi 
are seen in decaying organic substances, while the yeast 
fungi (blastomycetes) set up alcoholic fermentation. Morph- 
ology.*— As they occur in man, the mould fungi appear in 
the form of jointed or unjointed filaments (hyphse) and of 
ovoid or spherical cells. The filaments form compact 
masses (mycelia). The ovoid or spherical cells are the 
spores (conidia). 

Achorion Schoenleinii (favus fungus). — Present in favus, a skin 
disease appearing on the hairy parts of the scalp and characterized 
by dry, flat, yellow crusts, circular and depressed in the centre, 
through which the hairs proiect. If a small piece of a crust is 
placed on a glass with a little caustic potash and examined with a 
J^-inch objective, spores and a densely felted mycelium may be 
seen. 

Trichophyton Tonsurans — This is the fungus of herpes tonsurars 
and parasitic sycosis. The fungus filaments are present in the 
epidermis, the spores in the hair. Both fungi give characteristic 
cultures, which by inoculation reproduce their respective diseases. 

Microsporon Furfur (Pi'yriasis versicolor). — The yellowish epi- 
dermic scales produced in this affection may be confounded with 
pigmented spots. The fungus is demonstrated by adding to a few 
of the scraped off scales on an object glass, a few drops of caustic 
potash. Under the micros ope, a number of branched filaments 
(mycelium) and shining spores {conidia) are seen. The same pro- 
cedure is applicable in examining for other fungi in the hairs and 
scales of the skin. 



BACTERIA, 191 

Oidium Albicans. — This fungus forms the white patches known a-s 
thrush (or aphthce) present in the mouth, pharynx, oesophagus and 
stomach of weakly children and debilitated persons. It consists of 
branching filaments with shining sporesat the points of bifurcation. 

Aspergillus Glaucus and Niger. — Found in the external auditory 
meatus and no^e. They may also vegetate in the lungs (pneumo- 
oomycosis aspergillina) where they are usually secondary to destruc- 
tive processes (gangrene, tuberculous cavities, etc.). They form 
double-contoured, branched filaments containing pigmented 
spores. 



BACTERIA— (Schizomycetes). 

Morphology and Physiology.— These parasites 
are minute vegetable organisms of the lowest and simplest 
form and are widely distributed in the air, water, surface 
soil and about substances, animal and vegetable, undergo- 
ing decay. In their growth, the bacteria develop certain 
products ('ptomaines) which, if poisonous, are called toxines. 
It appears at present, as if the deleterious effects of bac- 
teria are largely due to ptomaines. Brieger has shown that 
the ptomaines cadaverin, neurin and mytilotoxin will 
produce in rabbits convulsions, paralysis, gastro-intestinal 
disturbances, etc. The ptomaine of tetanus (tetanin) will 
produce tetanus by inoculation. Coloring matters are 
often developed by bacteria. Bacteria are always present 
in the cavities of men and animals and are only active in 
ftie presence of moisture and may remain inert for a long 
time, either as spores or developed organisms to become 
again active under favorable conditions. At a temperature 
below 23°F., they are incapable of proliferation. They 
are most active at about the body temperature. In fluids 
all bacteria are killed when the boiling point of water is 
reached (212°F.) When dry, they are more resistant to 
heat than when moist. The spores are more resistant 
than the bacteria. Of all the agents which reduce the 
activity or destroy the bacteria, corrosive sublimate, even in 
extremely dilute solutions, is the most powerful. An 
aqueous solution of 1: 20,000 kills the spores of bacilli in 
ten minutes; and a solution of 1: 300,000 stops the germ- 
ination of bacterial spores. Disinfecting agents should be 
used in aqueous solution. In alcohol or oil, their action 



192 MANUAL OF CLINICAL DIAGNOSIS. 

is feeble. Bacteria may be pathogenic or non-pathogenic. 
The former multiply in the living organism and are the 
cause of infectious diseases. The non-pathogenic bacteria 
only vegetate on dead organic material (saprophytes) and 
are the cause of putrefaction and fermentation. 

Phagocytes. — This term has been applied to certain 
cells of the body which are capable of taking up into 
their protoplasm and destroying or digesting bacteria 
which get into the tissues. The resistance of the organism 
to certain infectious diseases may be explained by the 
theory of phagocytosis. 

Classification of Bacteria. — The following classifi- 
cation is based on the shape of the various known species 
and will no doubt be modified according to our increased 
knowledge of these organisms. 

1. Spheroidal bacteria (micrococci). — They may occur in 
beaded chains (streptococci), in pairs (diplococci), in masses 
(zooglea). or in grape-like groups (staphylococci). Path- 
ogenic micrococci have been found in the following diseases: 
diphtheria, scarlatina, ulcerative endocarditis, erysipelas, 
cerebro-spinal meningitis, pneumonia, osteo-myelitis, 
periositis, pyaemia, puerperal fever, gonorrhoea, and in 
connection with suppurative inflammation. 

2. Rod-shaped bacteria (bacilli). — This form of bacterium 
may form long, slender, filiform bacilli (leptothrix). Path- 
ogenic bacilli have been found in: malignant pustule, 
tuberculosis, typhoid fever, leprosy, Asiatic cholera and 
glanders. 

3. Spiral-shaped bacteria. — The most important species 
of this group is the spirillum of relapsing fever. 

METHOD OF DEMONSTRATING THE BACTERIA. 

For clinical purposes the color ; n^of micro-organisms in a dried, 
cover-glass preparation is generally employed, but in a few instances 
this procedure will not suffice, necessitating artificial cultivation 
of bacteria and inoculation into healthy animals. 

METHOD OF MAKING DRIED COVER GLASS 
PREPARATIONS. 

Spread with a sterilized needle (sterilized by heating in a flame 
and allowing to cool) the fluid to be examined on a clean cover- 



BACTERIA 193 

glass. With another cover-glass rub both together so that a thin 
film of the fluid is deposited on each. The cover-glasses are next 
dried by gentle heating over a flame which fixes and renders insol- 
uble any albuminous matter mixed with the bacteria. The next 
step is staining of the preparation. 

Staining.* — Any one of the following basic aniline colors, either 
in concentrated alcoholic or watery solution after filtration, may be 
employed; Fuchsia {muriate of rosaniline), methyl blue, methyl- 
violet, gentian-violet, Bismarck brown (vesuvin) or malachite. To 
the cover-glass preparation a few drops of any of the above solutions 
may be added and the staining is usually complete in two or three 
minutes. The cover-glass is next washed in water and placed on 
a slide when it is ready for the microscope. If the specimen is to 
be a permanent one, then the cover-glass is allowed to dry after 
washing in water when it is mounted in balsam. Balsam softened 
with oil of cedar or xylol is usually used, because chloroform will 
decolorize the bacteria. 

Nearly all the micro-organisms may be shown with any of the 
basic aniline colors except the tubercle bacillus {see page 65). 

To stain the gonococci {Neisser's method) press a drop of gonor- 
rheal pus between two cover-glasses, after which they are drawn 
apart, allowed to dry and then stained with methyl blue. Accord- 
ing to Steinschneider, the application of the Gram method of stain- 
ing is necessary to the satisfactory study of the gonococcus 
inasmuch as the only positive characteristic of this coccus is, that 
it is not stained by this method, while nearlv all other diplococci, 
found in the urethra are colored thereby. The bacilli of syphilis 
are conveniently stained according to the method of Giacomi. 
The cover-glass preparations are stained for a few minutes in a 
heated solution of fuchsin in aniline w T ater, then washed in water 
containing a few drops of a solution of chloride of iron ; washed, 
and then decolorized in a concentrated solution of chloride of iron. 
The syphilis bacilli are colored red while all other bacteria are 
decolorized. 

Gram's Method. — For isolated staining of the bacteria, this 
method is to be recommended. 

Solution 1. A saturated solution of gentian violet in aniline water. 

Solution 2. Solution of iodine in iodide of potash (iodine, 15 
grains, iodide of potash, 30 grains, distilled water, 9>£ ounces). 

Solution 3. Absolute alcohol. 

Solution 4. Saturated watery solution of Bismarck brown. 

The cover-glass preparation is placed in solution 1, for three 
minutes ; then in solution 2, for about two minutes ; then in solu- 
tion 3, until the preparation is decolorized. The micro-organisms 
are now stained a bluish black ; but in order to make the colored 

♦All the materials, instruments, microscopes, etc., needed for bacteriological 
study, can be obtained at the opticians, Henry Kahn <fe Co., 642 Market street, 
and Hirsch, Kahn & Co., 333 Kearny street, San Francisco. 



194 MANUAL OF CLINICAL DIAGNOSIS. 

microbes more evident, solution 4, is used for back-ground stain- 
ing. The preparation may be examined in water or dried and 
examined in balsam. 

a b c <j e 

& K s> <# 

Fig. 28. 

a. Streptococcus erysipelatis. b. Bacillus tuberculosis, c. Bacil- 
lus leprae, d. Gonococcus. e. Pneumococcus. f. Bacillus typho- 
sus, g. Bacillus anthracis. h. Spirillum of recurrent fever, i. 
Comma-bacillus of Asiatic cholera. 

In examining stained bacteria, good homogeneous immersion 
lenses (not less than r V) and an achromatic condenser of approved 
pattern, are indispensable. The condenser is best used without 
the diaphragm. 



APPENDIX. 



THE NERVOUS SYSTEM. 

EXAMINATION OF THE MIND. 

Disturbances of Consciousness. — Stupor, sleepi- 
ness from which the patient is easily awakened. Sopor, 
sleepiness from which the patient is aroused with difficulty. 
Coma, complete loss of consciousness from which the pa- 
tient cannot be aroused. 

Coma may result from traumatism, organic disease of the 
brain, epilepsy, diabetes, sunstroke, iirwmia, infectious dis- 
eases, hysteria, carcinoma, and from drugs {alcohol and 
opium). The following points are of value in differenti- 
ating coma. Evidences of paralysis and conjugate devia- 
tion of the eyes speak for apoplexy ; albumen and casts in 
the urine, and convulsions and vomiting at the beginning 
of coma, speak for urmmia ; in opium poisoning, the con- 
tracted pupils and slow respiration, are characteristic. 

Delirium is a wandering of the mind, manifested by 
a rapid flight of ill-assorted thoughts, which are unintelli- 
gible. It may result from i anition, alcoholism, urmmia, 
infectious diseases, and hysteria. 

Acute Delirium (Bell's Mania) is a disease running a 
rapidly fatal course. Its cause is unknown, as there are no 
definite post-mortem lesions. In delirium associated with 
insanity, the patient is usually in good health in all save 
his intellect. 

Vertigo (dizziness) is a temporary loss of conscious- 
ness. It is symptomatic of a large number of conditions. 
It may only indicate a sense of unstable equilibrium, as 
occurs in diplopia. Vertigo may result from : Congestion 
or ancemia of the brain, cerebral neurasthenia, organic dis- 
ease of the brain (tumors, especially of the vermiform pro- 
cess) and cord {multiple sclerosis and locomotar ataxia), dis- 



198 MANUAL OF CLINICAL DIAGNOSIS. 

eases of the stomach {vertigo a stomacho Icesa), diseases of 
the ear (vertigo ab aurce Icesa), and from the action of cer- 
tain toxic agents (lead, alcohol, belladonna). 

Meniere's Disease (labyrinthine vertigo) is an affec- 
tion depending upon disease of the internal ear, and charac- 
terized by paroxysmal vertigo, associated with deafness and 
ringing in the ears (tinnitus aurium). 

Kinging or subjective noises in the ear may be classified 
as central and peripheral. To the former belong those 
noises produced exclusively by pathological changes of the 
structures of the labyrinth ; and peripheral, to those due to 
causes external to the labyrinthal structures. Noises orig- 
inating in the labyrinth may be caused by exudations, in- 
creased pressure, anaemic and hypersemic conditions, and 
from the action of drugs. These noises always accompany 
a disturbance in hearing. Catarrh of the middle ear fre- 
quently gives' rise to entotic or subjective noises. Some- 
times the noises come from the vessels, particularly the 
carotid, which passes in close proximity to the ear. Other 
noises emanate from the jugular fossa, and others are pro- 
duced by muscular contraction, particularly of the mas- 
seter. 

Trance is a condition in which the patient shows no 
apparent signs of life. It may occur after attacks of hys- 
tero-epilepsy. 

Ecstasy is a condition in which the mind is completely 
absorbed with some delusion. 

Somnambulism is a condition in which the patient 
executes automatically various feats — such as writing, talk- 
ing, walking, etc. It occurs in hysteria, and under the 
influence of hypnotic suggestion. 

Catalepsy. Vide p. 172. 



DIAGNOSIS OF INSANITY. 

Hallucination is the perception of objects which have 
no real existence. The hallucination may be of taste, smell, 
vision, hearing and tact. If a person sees men where there 
are no men, he has an hallucination of vision. 



199 DIAGNOSIS OF INSANITY. 

Illusion is the misinterpretation of the character of an 

object, which has no real existence. If a person sees a 
chair and calls it a man, he has an illusion. 

Delusion has no direct connection with sensation in 
any form. It results from disturbances in reasoning. A 
person who asserts he is the Almighty labors under a delu- 
sion. An expansive delusion or a delusion of grandeur i, 
one which exalts its possessor. The grandiose ideas may 
embrace the possession of fabulous wealth, the undertaking 
of gigantic enterprises, etc. 

Imperative Conceptions are ideas which the patient 
knows are absurd, but which nevertheless occur to him 
and dominate his thoughts, and often direct his actions. 
When he is unable to recognize the absurdity of his concep- 
tion, it becomes a delusion. 

Morbid Impulse is an irresistible desire to commit an 
act, which the patient knows to be wrong. 

Moral Insanity is a congenital or acquired condition, 
of which depravity and absence of moral understanding 
constitute the chief manifestations. 

Periodical Insanity (Folie circulaire) is character- 
ized by alternating attacks of melancholia and mania, or 
mania and melancholia, returning at stated intervals. 

The chief forms of insanity are mania, melancholia, mo- 
nomania, dementia, idiocy and imbecility. 

Mania is increased mental and physical activity. All 
sensations are exalted. The patients cry, laugh, sing and 
dance. They are in constant motion. Usually there is no 
elevation of temperature. Mania transitoria is a sthenic 
variety of mania, which lasts but a few hours or a day. 

Melancholia is characterized by mental depression. 
According to the degree of depression there are three forms 
of melancholia : 1. simple; 2. agitated; 3. attonita. In all 
forms illusions and hallucinations are common. In melan- 
cholia attonita the patients are stupid, and. remain in one 
position however uncomfortable. Nutritive and vascular 
disturbances attend this kind of melancholia. 

Monomania signifies partial insanity on one subject, 
the mental powers in other respects being normal. The 



200 MANUAL OF CLINICAL DIAGNOSIS. 

delusions of monomania may include an endless variety of 
ideas. A monomaniac may, from the force of delusions or 
impellant ideas, commit theft (kleptomania) or arson (pyro- 
mania). 

Imperative Conceptions occur in persons of a neu- 
ropathic constitution, in whom they may develop whenever 
the general nutrition of the body is lowered. The patients 
may fear contamination (mysophobia), and avoid touching 
articles previously used. Some even forego eating, believ- 
ing the food to be unclean. Cases of perverted sexual in- 
stinct may be included under this caption. 

Dementia may be divided into the following forms : 

1. Senile dementia which results from senile disturb- 
ances of nutrition occurring in the brain. It is manifested 
by defective memory, apoplectic attacks, vertigo, insom- 
nia, and mental depression. Ordinary insanity occurring 
in old people, must not be confounded with senile de- 
mentia. 

2. Terminal dementia is weakness of the mind resulting 
from uncured cases of mental disease. 

3. Paralytic dementis (general paralysis of the insane) is 
a chronic disease of the brain and its membranes, marked 
by psychical and motor disturbances, leading to dementia 
and paralysis. In the prodromal stage the following symp- 
toms are usually present : irritability, loss of memory, ego- 
ism, apoplectiform attacks, tremor of the tongue and lips, 
slowness and hesitancy of speech, and inequality of the 
pupils. 

Symptoms of second stage : mental excitement, insomnia, 
delusions of grandeur, intensification of prodromal symp- 
toms, spastic or tabetic gait, and monoplegic or hemiplegia 
paralysis. Syphilis is the chief etiological factor aided by 
excesses of all kinds. The average duration of the disease 
is three or four years, and is invariably fatal, although 
lucid intervals or remissions may occur lasting several 
months. 

Idio3y is a result of arrested brain development and is 
often associated with deformities and malformations of the 
body. The following forms of idiocy are recognized : 

1. Genetous idiocy which results from intrauterine dis- 



RELATION OF DISEASES TO INSANITY. 201 

turbances. Two-thirds of the children die of consumption. 
In 517 cases examined by Howe, 21 were blind, L2 were 
deaf. 23 had some deformity of the mouth and nose, 54 had 
deformed hands or feet, and in 96 cases paralyses were 
present. They usually have the vaulted palate, protruding 
jaw and teeth, and retain an infantile appearance. 

2. Microcephalic idiots have a narrow head tapering 
toward the top. 

3. Eclamptic idiocy is produced by the convulsive seizures 
of infancy and childhood. 

4. Epileptic idiocy is produced by epilepsy in infancy or 
childhood. 

5. Hydrocephalic idiocy is produced by hydrocephalus. 

6. Paralytic idiocy follows a celebral lesion. 

7. Traumatic idiocy is produced by traumatism. 

8. Idiocy by deprivation occurs when a child at birth or 
early life is deprived of two or more of its senses. 

9. Cretinism. — Cretinoid idiots are confined to definite 
localities, usually in closed narrow mountain passes. 

Cretins have a stupid, apathetic appearance, short, broad 
features, large mouth, hands and feet, thick lips and 
tongue (macroglossia), harsh voice, shuffling gait and goitre 
(characteristic). Cretinism differs from idiocy in its sus- 
ceptibility to treatment. 

Imbecility is a less profound arrest of the mental pro- 
cesses as compared with idiocy. Imbeciles are susceptible 
of more or less education. 



RELATION OF VARIOUS DISEASES AND 
FUNCTIONS TO INSANITY. 

Hypochondria. — Tn individuals predisposed to mental 
and nervous diseases, disturbances of the physical functions 
may lead to a condition of the mind in which the patient 
constantly fixes his attention on the morbid sensations. If 
he suffers from dyspepsia, he imagines he has cancer of the 
stomach. Such a condition is known as hypochondria. 
Hypochondria becomes melancholia when the imaginary 
troubles of the patient are actual delusions out of which he 
cannot be reasoned. Hypochondria is a much abused sub- 



202 MANUAL OF CLINICAL DIAGNOSIS. 

terfuge employed by the physician when he is incapable of 
detecting a cause for the disease. All hypochondriacs have 
a tangible reason for their complaints. 

Epilepsy. — Insanity may follow the convulsions (post- 
epileptic insanity), or it may precede them. After an epi- 
leptic attack, the patient may be in a state of irritability 
and excitement (post-epileptic delirium); he may have 
maniacal attacks or hallucinations. 

Hysteria. — In hysterical individuals, there is always a 
maniacal element in which the self-control, moral element 
or the feelings are involved. The insane manifestations 
may be mania, melancholia, or dementia. The diagnosis 
is based on the history of the case and the presence of 
hysterical stigmata (disturbances of sensation and motion, 
globus, etc.). Hystero- Epilepsy may simulate true epilepsy. 
The following are the chief points of differentiation : 

Epilepsy: no apparent cause for attack, sudden onset, 
biting of tongue, of short duration, micturition and defeca- 
tion may occur during the attack, convulsion is manifested 
by rigidity followed by jerking. Eise of temperature com- 
mon. 

Hystero-Epilepsy : caused by emotion, gradual onset, the 
convulsion consists of rigidity alone leading to arching of 
the back, the tongue is rarely bitten, the convulsions are of 
longer duration, micturition and defecation rarely occur, 
firm pressure over the ovaries may inhibit or excite an 
attack. There is only exceptionally a rise of temperature. 

Chorea. — In an extreme form of this affection, which is 
more common in adult women and may develop during 
pregnancy (usually during the first five months), there may 
be maniacal excitement (chorea insaniens). Psychical dis- 
turbances are common in chorea and are manifested by 
irritability of temper, emotional outbreaks and mental 
enfeeblement. 

Huntingdon 9 s Chorea (chronic chorea) is an hereditary 
affection occurring in adult life, and is commonly followed 
by some mental disorder which terminates in dementia. 

Physiological Crises (puberty, maternity, meno- 
pause, senility). 



RELATION OF DISEASES TO INSANITY. 203 

Puberty. — At this period of life in both sexes, a moral 
perversity may occur, manifested by a sudden disposition 
to steal, lie, swear, etc. It may be of long duration and 
finally result in incurable insanity. In girls, when men- 
struation is first established, excitement with delusions 
may occur. 

Maternity. — About fifteen per cent, of cases of insanity 
among women occur during the performance of the func- 
tions of pregnancy, parturition, and lactation. 

Puerperal mania usually occurs two or three weeks after 
delivery. The attack is preceded by excitement, insomnia, 
constriction of the head and disturbance of vision. The 
insanity, when fully developed, may amount to delirious 
mania. 

Menopause. — Nervous and mental symptoms of a mild 
character are common to all women during this period. 
Mental disorder may occur during any stage of the meno- 
pause, and is characterized by the various shades of melan- 
cholia. 

Senility. — In men between the ages of 55 and 65, there 
is a period corresponding to the menopause of women. In 
this period retrograde changes involving the arteries and 
cortex of the brain occur, which conduce to mental dis- 
turbances. 

Alcoholism. — The long-continued use of alcohol may 
lead to all grades of mental impairment from enfeeblement 
of the mind to dementia {alcoholic dementia). 

Dipsomania constitutes a manifestation of chronic alco- 
holism in which the patient is impelled periodically to 
indulge in a morbid craving for alcohol. 

Delirium Tremens (mania a poke) follows the long-con- 
tinued use of alcohol. It may occur during the time the 
patient is indulging himself in alcohol or after its sudden 
withdrawal. Sometimes an accident or acute infectious 
disease ( pneumonia) may determine the onset of the deli- 
rium. Symptoms : The patient talks constantly and has 
hallucinations of sight and hearing. He sees rats, mice, 
and hears unusual sounds, there is muscular tremor, rise 
of temperature and insomnia. Abatement of restlessness 
and tendency to sleep usually terminate the attack. Ee- 
covery is usual. 



204 MANUAL OF CLINICAL DIAGNOSIS. 

The effects of alcohol as a tissue poison is manifested by 
degenerative changes of the parenchyma of the viscera, 
thickening and fibroid changes of the arteries, and fatty 
changes due to diminished oxidation of the tissues, since 
alcohol is consumed in lieu of fat. The habitual use of 
alcohol leads specially to the following affections : hemor- 
rhagic pachymeningitis, alcoholic neuritis, paralytic de- 
mentia, catarrh of the stomach, cirrhosis of the liver, arte- 
riosclerosis and granular kidney. 

Toxic Insanities result from the action of certain 
toxic agents, such as morphine, lead, and mercury. 

Organic Dementia has its anatomical substratum in 
cerebral organic affections, such as embolism, thrombosis, 
softening and apoplexy. The mental disturbances result 
from defective nutrition of the cortical centers. The men- 
tal alienation is usually characterized by loss of memory, 
although mental exaltation or depression may be present. 
The patients are usually stupid and silly. 

Syphilis may relead to insanity as the result of the 
luetic poison on the brain (cerebral syphilis). Cerebral 
syphilis may first show itself by sudden and violent deli- 
rium. Some cases show a prolonged torpor. Syphilis not 
only predisposes to, but directly produces dementia para- 
lytica. Syjjhilophobia is a condition in which the patient 
imagines he has acquired syphilis, or believes that every 
simple skin lesion may be a manifestation of it. 

Etiology of Insanity. — The causes may be predis- 
posing and exciting. To the former belong the excessive use 
of alcohol, tobacco, coffee and anxiety. Insanity is equally 
frequent in both sexes. Before puberty insanity is rare ; 
if occurring before this period it may be congenital or 
acquired from certain habits, as masturbation, or from dis- 
eases, such as epilepsy, chorea, infectious diseases, etc. 
The greater percentage of insanities occurs, in women, 
between 20 and 35 ; and in men, between 30 and 50 years 
of age. Heredity is an important factor in the etiology of 
insanity. 

Exciting causes. — Fright, worry, organic affections of the 
brain and the acute infectious diseases. 

Prognosis of Insanity. — In simple cases of mania, 
the prognosis is favorable. If recovery does not occur, it is 



RELATION OF DISEASES TO INSANITY. 205 

followed by mental weakness. A large number of cases of 
Melancholia recover, but the prognosis is not so favorable 
as in mania. Kecovery is slow and marked by periods of 
exacerbation. If recovery does not take place, it termi- 
nates into either chronic melancholia or dementia. Senile 
dementia lasts from about one to three years. The prog- 
nosis of hypochondria is always doubtful ; it begins and 
progresses slowly and may have remissions. Dementia 
paralytica is unfavorable ; patients rarely living over two, 
three or four years. 

Topography of the Brain. — To locate the fissures 
and convolutions of importance on the surface of the brain, 
the following method of Eeid is recommended for its sim- 
plicity. Keid's base line runs backward from the infra- 
orbital ridge through the middle of the external auditory 
meatus, and prolonged to the middle line of the head pos- 
teriorly. The fissure of Sylvius runs from a point an inch 
and a quarter behind the external angular process of the 
frontal bone to a point three-fourths of an inch below the 
most prominent point of the parietal eminence. Measuring 
from above backward, the first three-fourths of an inch 
will represent the main fissure ; the rest indicates the hori- 
zontal limb. The ascending limb starts at a point three- 
fourths of an inch back of the anterior extremity ; that is, 
two inches behind and slightly above the external angular 
process, and runs vertically upward and forward about one- 
fourth of an inch. 

To find the fissure of Rolando, draw the base line and 
the lines for the great longitudinal fissure (an imaginary 
line corresponding to the course of this fissure) and the 
fissure of Sylvius. Then draw two lines perpendicular to 
the base line ; one from the depression in front of the 
external meatus and the other from the posterior border of 
the mastoid process at its root. We now have on the sur- 
face of the head a four-sided figure, bounded above and 
below by the lines for the longitudinal fissure and the 
horizontal limb of the fissure of Sylvius, respectively, and 
in front and behind by the two perpendicular lines just 
described. Now draw a diagonal line from the posterior 
superior angle to the anterior inferior angle. This corre- 
sponds to the fissure of Rolando, which, as a rule, does not 
quite join the fissure of Sylvius. 



206 



MANUAL OF CLINICAL DIAGNOSIS. 



LOCALIZATION OF THE FUNCTIONS OF THE 
SEGMENTS OF THE SPINAL CORD.— (Starr.) 



SEGMENT. 


MUSCLES. 


KEFLEX. 


SENSATION. 


2d and 3d 

cervical 


Sterno-mastoid, tra- 
pezius, scaleni and 
neck, diaphragm. 


Hypochondrium (?) ; sud- 
den inspiration produced 
by sudden pressure be- 
neath the lower border 
of ribs. 


Back of head to 
vertex ; neck. 


4th 
cervical 


Diaphragm, deltoid, 
biceps, coraco-bra- 
chialis, supinator 
longus, rhomboid, 
supra- and infra- 
spinatus. 

Deltoid, biceps, 
coraeo - brachialis, 
brachialis anticus, 
supinator longus, 
supinator b re vis, 
rhomboid, teres mi- 
nor, pectoralis, ser- 
ratus magnus. 

Biceps, brachialis 
anticus, pectoralis 
( clavicular part ), 
serratus magnus, 
triceps, extensors 
of wrist and fingers, 
pronators. 


Pupil, 4th to 7th cervical ; 
dilatation of the pupil 
produced by irritation of 
the neck. 


Xeck, upper shoul- 
der, outer arm. 


5th 
cervical 


Scapular, 5th cervical to 
1st dorsal ; irritation of 
the skin over scapula pro- 
duces contraction of the 
scapula muscles, supina- 
tor longus ; tapping its 
tendon in wrist produces 
flexion of forearm. 


Back of shoulder 
and arm ; outer 
side of arm and 
forearm, front and 
back. 


6th 
cervical 


Triceps, 5th to 6th cervi- 
cal ; tapping elbow ten- 
don produces extension 
of forearm ; posterior 
wrist, 6th to 8th cervical ; 
tapping tendon causes 
extension of hand. 


Outer side of fore- 
arm, front and 
back ; outer half 
of hand. 


7th 
cervical 


Triceps (longhead), 
extensors of wrist 
and fingers, prona- 
tors of wrist, flexors 
of wrist, subscapu- 
lar, pectoralis (cos- 
tal part), latissimus 
dorsi, teres major. 


Anterior wrist, 7th to 8th 
cervical ; tapping ante- 
rior tendons causes flex- 
ion of wrist ; palmar, 7th 
cervical to first dorsal ; 
striking palm causes clo- 
sure of fingers. 


Inner side of back 
of arm and fore- 
arm ; radial half 
of hand. 


8th 
cervical 


Flexors of wrist and 
fingers, intrinsic 
muscles of hand. 


: 


Forearm and hand, 
inner half. 


1st 
dorsal 


Extensors of thumb, 
intrinsic hand mus- 
cles, thenar and hy- 
pothenar eminen- 
ces. 





Forearm, inner 
half; ulnar distri- 
bution to hand. 



SPINAL LOCALIZATION. 



20? 



MENT. 


MUSCLES. 


REFLEX. 


SENSATION. 


2d to 12th 
dorsal 


Muscles of back and 
abdomen, erectores 
spins. 


Epigastric, 4th to 7th dor- 
sal ; tickling mammary 

region causes retraction 

of the epigastrium ; ab- 
dominal, 7th to 11th dor- 
sal ; striking side of ab- 
domen causes retraction 
of belly. 


Skin of chest and 
abdomen in bands 
running around 
and downwards 

corresponding to 
spinal nerves ; up- 
per gluteal re- 
gion. 



SPINAL LOCALIZATION. 



1st 
lumbar 


Ilio-psoas, sartorius, 
muscles of abdo- 
men. 


Cremasteric, 1st to 3d lum- 
bar ; striking inner thigh 
causes retraction of scro- 
tum. 


Skin over groin 
and front of scro- 
tum. 


2d 
lumbar 


Ilio-psoas, sartorius, 
flexors of knee (Re- 
mak) quadriceps, 
femoris. 


Patella tendon ; striking 
tendon causes extension 
of leg. 


Outer side of 
thigh. 


3d 
lumbar 


Quadriceps femo- 
ris, inner rotators 
of thigh, abductors 
of thigh. 


— 


Front and inner 
side of thigh. 


4th 
lumbar 


Abductors of thigh, 
adductors of thigh, 
flexors of knee (Fer- 
rier), tibialis anti- 
cus. 


Gluteal, 4th and 5th lum- 
bar ; striking buttock 
causes dimpling [in fold 
of buttock. 


Inner side of thigh 
and leg to ankle ; 
inner side of foot. 


5th 
lumbar 


Outward rotators of 
thigh, flexors of 
knee (Ferrier), flex- 
ors of ankle, exten- 
sors of toes. 





Back of thigh, 
back of leg, and 
outer part of foot. 


1st and 2d 
sacral 


Flexors of ankle, 
long flexors of toes, 
peronei, intrinsic 
muscles of foot. 


Plantar; tickling sole of 
foot causes flexion of 
toes and retraction of leg. 


Back of thigh, leg, 
and foot, outer 
side. 


3d to 5th 
sacral 


Perineal muscles. 


Foot reflex, Achilles ten- 
don ; over extension of 
foot causes rapid flexion, 
ankle clonus, bladder and 
rectal centres. 


Skin over scrotum, 
anus, perineum, 
genitals. 



208 



MANUAL OF CLINICAL DIAGNOSIS. 



DIAGNOSIS OF DISEASES OF THE NERVOUS 

SYSTEM. 

DISEASES OF THE NERVES. 



Morbid Anatomy. 



General Symptoms. 



Characteristic Symptoms. 



1. NEURITIS. 

Inflammation localized 
in a single nerve. The 
sheath may be involved 
or the axis cylinders {pa- 
renchymatous neuritis). 



Slight constitutional 
disturbances, pain along 
the nerve, muscular pow- 
er is impaired and trophic 
disturbances are present. 



2. MULTIPLE NEURITIS, (Polyneuritis.) 



Inflammation involv- 
ing a large number of 
nerves. 



The onset is like that 
of an acute infectious 
disease. Pain, numbness, 
loss of power and the re- 
flexes, tenderness of the 
nerve trunks and degen- 
erative atrophy of the 
muscles. 



Pain is constant. There 
is first hyperesthesia and 
later anaesthesia of the 
affected parts. The af- 
fected nerve is tender 
and thickened. 

Like the foregoing, be- 
sides the constitutional 
symptoms. Wrist drop, 
when the upper, andjbol 
drop, when the lower ex- 
tremities are involved. 
Steppage gait; the foot is 
raised high, toe raised, 
and the heel brought 
down first. 



DISEASES OF THE SPINAL CORD AND MENINGES. 



1. PACHYMENINGITIS CERVICAEIS. 



Inflammation of the 
Dura mater caused by 
caries or tuberculosis of 
the vertebrae, syphilis, 
etc. 
2. LEPTOMENINGITIS. 

Inflammation of the 
soft spinal meninges, 
which may be acute or 
chronic. 



The first stage is mark- 
ed by pains, the second 
stage by paralysis. The 
disease usually lasts over 
years. Recovery rare. 



Moderate fever, pains 
in the back, rigidity of 
spinal muscles and para- 
lysis. 

3. HE3IATORRHACHIS. (Meningeal Apoplexy 

The symptoms resem- 
ble spinal meningitis, 
only that the onset is 
very sudden. There is 
complete freedom from 
disturbances of con- 
sciousness. 



Pains and stiffness in 
the neck, paresthesias in 
the arms followed by pa- 
ralysis. 



Stiffness of the muscles 
of the back and tender- 
ness of the vertebras. 



The hemorrhage may 
be extra-meningeal (be- 
tween the dura and spi- 
nal canal) or intra-menin- 
geal (within the dura). 





If hemorrhage is in 
lumbar cord, the legs, 
bladder and rectum suf- 
fer. In dorsal cord, irri- 
tation of intercostal 
nerves. In cervical cord, 
motor and sensory dis- 
turbances in upper ex- 
tremities. 



DISEASES OF THE SPINAL CORD. 



DISEASES OF THE SPINAL CORD— Continued. 



Morbid Anatomy. 



Qeru red Symptoms. 



( 'haracteristic Symptoms. 



4. CAISSON DISK ASK. 

Liberation in the spinal 
cord of bubbles of nitro- 
gen which have been ab- 
sorbed by the blood un- 
der high pressure, result- 
ing in myelitis and hem- 
orrhages. 

5. ACUTE 3IYEEITIS. 

When a transverse sec- 
tion of the cord is in- 
volved it is called trans- 
verse myelitis; when the 
gray matter is involved, 
central myelitis: when a 
large vertical section of 
the~ cord is involved, dif- 
fuse myelitis. 



(Diver's 1'aralysis). 

Found in divers and 
workers in eaisp tns. Par- 
aplegia which follows 
on returning from the 
compressed atmosphere 
to the surface. 



Acute central myelitis : 
sensory and trophic dis- 
turbances, paralysis of 
bladder and rectum, rap- 
id wasting, electrical 
changes and fever. Trans- 
verse myelitis ; fever, gir- 
dle pain at level of dis- 
ease, flabby paralysis of 
the muscles, bed sores, 
and anaesthesia. 



6. POLIO-3IYEEITIS ANTERIOR ACUTA. 



The anterior horns of 
the gray matter are atro- 
phied, the motor cells 
are degenerated. The 
anterior'nerve roots and 
affected muscles are atro- 
phied. The cervical or 
lumbar enlargements are 
usually affected. 

7. LANDRY'S PARAEY 

Occurs in males be- 
tween the twentieth and 
thirtieth years. The dis- 
ease is like a peripheral 
neuritis, although no def- 
inite demonstrable le- 
sions have been found. 



<s 



Sudden onset of the 
symptoms. 



Usually occurs during 
the first three years of 
life. Onset is abrupt. 
No sensory disturbances. 
The paralysis is confined 
to certain groups of mus- 
cles in the upper and 
lower extremities. 



Transverse myelitis of 
the cervical region ; paral- 
ysis of motion and sensa- 
tion in upper extremi- 
ties, vomiting, slow 
pulse, contraction of the 
pupils. Myelitis of the 
dorsal region, ; motor and 
sensory paralysis in the 
lower extremities. 



Acute disease, occur- 
ring in young children 
with fever, loss of power 
in certain muscles and 
rapid atrophy. The re- 
flexes are absent. 



SIS. (Acute Ascending.) 

An advancing paraly- 
sis beginning in the legs 
and extending rapidly to 
the trunk and arms, end- 
ing usually in implica- 
tion of the respiratory 
muscles. 



Rapidly advancing mo- 
tor paralysis without af- 
fecting the sphincters, 
without wasting or elec- 
trical changes in the 
muscles, absence of tro- 
phic lesions and fever. 



SPASTIC PARAPLEGIA 

In primary spastic para- 
plegia there is primary 
sclerosis of the lateral 
tracts. Secondary spastic 
paraph-gin is secondary 
sclerosis of the lateral 
tracts after any trans- 
verse lesion of the cord. 



(Lateral Sclerosis. 

The patient complains 
of a tired feeling and 
stiffness in the legs. The 
reflexes are so increased 
that the slightest touch 
upon the patella tendon 
results in an active knee 
jerk. 



Characteristic gait (p. 
3). Loss of power with 
spastic contraction of the 
muscles of the lower ex- 
tremities, exaggerated 
knee jerk, presence of 
ankle clonus. No mus- 
cular wasting or disturb- 
ance of sensation. 



210 



MANUAL OF CLINICAL DIAGNOSIS. 



DISEASES OF THE SPINAL CORD— Continued. 



Morbid Anatomy. 



(ri a, ml Symptoms. 



( 1 haracteristic Symptom*. 



9. HEREDITARY ATAXIA. (Friedreich's Ataxia.) 



Extensive sclerosis of 
the posterior and lateral 
columns of the cord. 



A family disease oc- 
curring in early life and 
characterized by almost 
the same clinical feature 
as tabes dorsalis. 

10. LOCOMOTOR ATAXIA. (Tabes Dorsalis.) 

Pre-ataxic stage. Light- 



The peripheral nerves 
and posterior roots of 
the cord are degenerated. 
The posterior columns of 
the cord are sclerotic, 
especially in the dorsal 
and lumbar regions. The 
membranes over the pos- 
terior columns are in- 
flamed. 



ning pains in the legs, 
ptosis, Argyll-Robertson 
pupil, loss of the knee 
jerk. 

Ataxic stage. Symptom 
of Romberg (p. 170), 
ataxic gait (p. 3), light- 
ning pains continue, sen- 
sory disturbances and 
gastric crises. 

Paralytic stage. Loss of 
motor power. 



11. SYRINGO-MYELIA. 

There is an overgrowth 
of embryonal neuroglia 
in which degeneration 
occurs, leading to a cav- 
ernous condition of the 
cord. It usually involves 
the posterior portion of 
the cord, and extends 
into one posterior cor- 
nu. 

13. C03IPRESSION MYELITIS. 



A disease of slow de- 
velopment, persisting a 
long time, appearing 
about the time of puber- 
ty, and characterized by 
neuralgic pains, wasting 
of the muscles, and loss 
of painful and thermic 
sensations. 



The developed symp- 
toms may be due to com- 
pression of the verte- 
bral column (deformity), 
nerve roots (pains), or 
cord (paralysis). 



Interference of the 
functions of the spinal 
cord by slow compres- 
sion, and produced by 
any of the following 
causes : caries of the 
spine, tumors, trauma, 
and aneurism. 

13. BROWN SEQUARD'S PARALYSIS. 

Spinal hemiplegia. 
Loss of sensation on the 
side opposite to the le- 
sion. The tactile sensa- 
tion is usually unim- 
paired. The reflexes are 
increased on the side of 
the lesion. 



Destruction of one-half 
the cord by fracture, 
caries, tumors, stab- 
wounds, etc. 



A disease of childhood 
marked by incoordina- 
tion, nystagmus, scolio- 
sis, scanning speech and 
talipes equinus. 



Lightning pains, ab- 
sence of knee jerk, Ar- 
gyll-Robertson pupil, 
marked incoordination 
with no loss of muscular 
power, diplopia, optic 
atrophy, impotency and 
Romberg's symptom. 



Paralysis of an amyo- 
trophic type, with reten- 
tion of tactile and loss 
of thermic and painful 
sensations. 



Tenderness of the ver- 
tebral column, painful 
areas of the skin which 
are anaesthetic (ancedJiesia 
dolorosa) and deformity 
of the spine. The symp- 
toms develop slowly. 



Motor paralysis on the 
side of the lesion and a 
sensory paralysis on the 
opposite side. There is 
often hyperesthesia on 
the side of the motor 
paralysis. 



DISEASES OF THE BRAIN AND MENINGES. 



211 



DISEASES OF THE SPINAL CORD— Continued. 



Morbid Anatomy, 



Gft neral Symptoms. 



Characteristic Symptoms. 



14. AMYOTROPHIC LATERAL SCLEROSIS. 



Simultaneous implica- 
tion of the ganglionic 

colls of the gray anterior 
horns and the pyramidal 
or lateral tracts of the 
cord. 



The disease is first no- 
ticed in the arm, and is 
attended by paresis and 
wasting of the muscles 
of the hand and lingers. 
Other muscles become 
atrophied. At a later pe- 
riod of the disease the 
patient has bulbar symp- 
toms. 



The co-existence of 
muscular atrophy, in- 
crease of the tendon re- 
flexes, bulbar symptom* 
and absence of sensory 
and bladder disturb- 
ances. 



15. POLIOMYELITIS ANTERIOR CHRONICA. (Progressive Muscular 
Atrophy.) 



Atrophy of the mus- 
cles, atrophy of the an- 
terior roots, and atrophy 
of the ganglion cells of 
the anterior horns. The 
essential lesion is of the 
ganglion cells in the an- 
terior horns. 



It is a disease of adults 
occurring after the thir- 
tieth year, and mani- 
fested anatomically by 
degeneration of the gan- 
glion cells, and clinically 
by loss of power and 
atrophy of the corre- 
sponding muscles. The 
musclesof the hand are 
first affected. 



Muscular atrophy, in 
the adult beginning in 
the thumb muscles and 
slowly involving the in- 
terossei and lumbricales. 



16. GLOSSO-LABIO-LARYNGEAL 

(Duchenne's Disease.) 



PARALYSIS. (Bulbar Paralysis.) 



Degenerative atrophy 
of the nuclei of nerves 
that take their origin on 
the floor of the fourth 
ventricle. The degener- 
ation is rarely primary 
but secondary to some 
disease of the motor 
path. 



Impairment of speech, 
paralysis and atrophy of 
tongue, lips, and phar- 
ynx, inability to swallow, 
dribbling of saliva, sup- 
pression of the voice, dif- 
ficult respiration and dis- 
turbed cardiac rhythm. 



Disturbances confined 
to the motor functions 
presiding over the mus- 
cles of the tongue, lips, 
pharynx and larynx. 
There are no sensory dis- 
turbances. 



DISEASES OF THE BRAIN AND MENINGES. 



1. HEMORRHAGIC PACHYMENINGITIS, 



Found in insanity and 
chronic alcoholism/ Sub- 
dural hemorrhage in con- 
nection with atrophy of 
the convolutions. 



Headache is a promi- 
nent symptom, although 
the affection may exist 
without symptoms. 



Headache, abuse of 
alcohol and disturbances 
of intellection. 



212 



MANUAL OF CLINICAL DIAGNOSIS. 



DISEASES OF THE BRAIN— Continued. 



Morbid Anatomy. 



General Symptoms. 



Characteristic Symptom*. 



2. SIMPLE LEPTOMENINGITIS. 

The convexity of the Moderate fever, retrac- 
pia is usually affected, tion of the head, convul- 
It presents all the evi- sions, headache and co- 
dences of inflammation, ma. The prognosis is 
It maybe caused by trau- usually unfavorable, 
matism, rheumatism, and 
other infectious diseases, 
and extension of inflam- 
mation from ear. 

3. TUBERCULOUS MENINGITIS. 

The meninges at the Disease of childhood 
base of the "brain are usually. Begins insidi- 
most involved (basilar ously with nervous 
meningitis). The inflam- symptoms followed by 
mation of the membrane headache, shrill scream 
is a tuberculous one. (hydrocephalic cry), rigidi- 

ty of neck muscles, fe- 
ver, delirium, convul- 
sions and coma. 

4. CEREBRAL AN.E3IIA. 



Deficient supply of 
blood to the brain may 
be associated with gen- 
eral anaemia, aortic steno- 
sis and degeneration of 
the cerebral blood- ves- 
sels. 



The blood-vessels are 
atheromatous and occu- 
pied by miliary aneu- 
risms. The most fre- 
quent seat of the hemor- 
rhage is in the internal 
capsule. The hemor- 
rhage may be cerebral, 
meningeal, or intraventric- 
idar. 



Patient, usually with- 
out warning, becomes 
suddenly unconscious, 
with flushed face and 
stertorous breathing, ro- 
tation of the eyes to one 
side (conjugate" de?'iatio?i) 
and paralysis. Sensation 
is unaffected unless pos- 
terior limb of the inter- 
nal capsule is involved. 



Headache, stiffness 
and retraction of the 
neck muscles and vomit- 
ing. 



Pallor of the face, ver- 
tigo, dimness of vision, 
dilatation of the pupil, 
syncope, failure of mem- 
ory, etc. The symptoms 
are ameliorated after in- 
halation of nitrite of 
aniyl. 

5. CEREBRAL HYPEREMIA. 

Congestion of the brain There are no definite 
may be active, as occurs S3 T mptoms, in fact the 
in fevers, or passive from clinical picture may re- 
obstruction in the cere- semble that of cerebral 
bral sinuses and veins. anemia. 

6. CEREBRAL HE3IORRHAGE. (Apoplexy.) 



Acute beginning with 
epileptiform convul- 
sions, trismus, strabis- 
mus, rigidity of the mus- 
cles of the neck, vomit- 
ing, neuritis and tuber- 
cles in the choroid. 



The ophthalmoscope 
shows retinal anaemia. 
Head symptoms asso- 
ciated with anemia and 
improving after removal 
of the latter. 



The ophthalmoscope 
shows retinal hyperemia, 
There is usually head- 
ache and congestion of 
the face. 



Met with in aged indi- 
viduals in whom the ar- 
teries are atheromatous. 
Sudden loss of conscious- 
ness accompanied with 
paralysis. 



DISEASES OF THE BRAIJST. 



213 



DISEASES OF THE BRAIN— Continued. 



JTorbid Anatomy, 



ral Symptom*. Characteristic Symptoms. 



7. CEREBRAL EMBOLISM AND THROMBOSIS. (Cerebral Softening.) 

Emboli arc most fre- In embolism the onset Diagnosis of embolism : 



quent in a branch of the 

left middle cerebral ar- 
tery. The majority of 
emboli are derived from 
valves of the heart in 
endocarditis. Thrombi 
are most common in the 
middle cerebral and ba- 
silar arteries. 



is sudden without pro- 
dromes. Embolism of 
the left middle cerebral 
artery causes hemiplegia 
With aphasia. In throm- 
bosis the symptoms 
(headache, vertigo, in- 
somnia, etc.) are devel- 
oped slowly. 



presence of a cardiac le- 
sion, occurrence in the 

young, absence of pro- 
dromes and no uncon- 
sciousness during the 
attack. 



8. THROMBOSIS OF THE CEREBRAL VEINS AND SINUSES. 



Primary thrombosis is 
rare. Secondary thrombo- 
sis follows extension of 
inflammation from neigh- 
boring parts, such as dis- 
eases of the ear, fracture 
and erysipelas. 



The onset of the dis- 
ease is usually sudden 
and marked by symp- 
toms of septicemia. 
There is fever, rigors, 
pain in the occipital re- 
gion and the neck. 



9. CEREBRAL PARALYSIS IN CHILDREN. 



Atrophy and sclerosis 
of the cerebral convolu- 
tions and porencephalies 
(a cystic condition of the 
cortex). Difficult labor, 
injury with the forceps 
and infectious diseases 
are etiological factors. 

10. TUMORS OF THE BRAIN. 



The paralysis may be 
hemiplegic, diplegic, or 
paraplegic. It occurs at 
birth or during the first 
few years of life. The 
children may be imbe- 
ciles or idiots. 



The most common va- 
rieties are tubercle, gum- 
ma, glioma, cysts, sar- 
coma and carcinoma. 



Headache with local- 
ized tenderness, vomit- 
ing, optic neuritis, verti- 
go, failure of memory 
and symptoms resulting 
from pressure (paralysis, 
convulsions, etc.). 



11. ABSCESS OF THE BRAIN. 



In four-fifths of all 
cases, the abscess is soli- 
tary. The temporo- 
sphenoidal lobe and the 
cerebellum are the most 
frequent seats. 



A history of trauma- 
tism followed by fever, 
headache, delirium, 

vomiting and rigors. 
There may be otorrhea 
or some suppurating dis- 
ease. 



The diagnosis is diffi- 
cult, and can only be 
made if, in conjunction 
with the general symp- 
toms, signs are added pe- 
culiar to sinus thrombo- 
sis as, for instance, oede- 
ma of the eyelids and 
congestion of the retina 
point to involvement of 
the cavernous sinus. 

In more than half the 
cases, the paralysis is 
preceded by partial or 
general convulsions and 
loss of consciousness. 
Fever is usually present. 



Headache, optic neu- 
ritis and vomiting. The 
character and location of 
the tumor must be de- 
termined along with the 
existence of the growth. 



History of traumatism 
or existence of some 
suppurating disease fol- 
lowed by all the symp- 
toms of a brain tumor 
plus the fever. 



214 



MANUAL OF CLINICAL DIAGNOSIS. 



DISEASES OF THE BRAIN-Continued. 



Morbid Anatomy. 



General Symptoms. 



Characteristic Symptoms 



12. INSULAR SCLEROSIS. 

A disease occurring in 
middle-aged persons, of 
chronic course, and char- 
acterized by volitional 



Sclerosed patches dif- 
fusely distributed in the 
brain and cord, and con- 
sisting of an increased 
growth of connective tis- 
sue which destroys the 
medulla of the nerves, 
the axis cylinders per- 
sisting. 

13. DEMENTIA PARALYTICA 

Cerebral membranes 
are thickened and adhe- 
rent to the brain, the 
cortex is atrophied and 
there is an increase of 
connective tissue and de- 
generation of nerve fi- 
bres and ganglionic cells. 



tremor, scanning speech, 
nystagmus and vertigo. 



Tremor on attempting 
movements, nystagmus, 
scanning speech and 
spastic weakness of the 
legs. 



(General Paresis.) 

Delusions of grandeur, 
trembling of the tongue, 
slow speech, unequal pu- 
pils, shuffling gait and 
Argyll-Robertson pupil. 



A chronic, progressive 
meningo-encephalitis as- 
sociated with psychical 
and motor disturbances 
leading to paralysis and 
dementia. 



14. HYDROCEPHALUS. 

Accumulation of fluid 
within the ventricles of 
the brain, associated 
with a large head, su- 
tures and fontanelles. 
The condition may be 
congenital or acquired. 



Congenital hydroceph- 
alus occurs in the first 
few years of life asso- 
ciated with impaired in- 
telligence, increased re- 
flexes, convulsions and 
various motor phenom- 
ena. 



Globular enlargement 
of the head, open sutures 
and fontanelles and im- 
paired intelligence. The 
congenital cases usually 
die within the first four 
or five years. 



FUNCTIONAL NERVOUS DISEASES. 



1. ACUTE DELIRIUM. 

There are no constant 
pathological lesions. 
Acute infection is a pos- 
sible factor in the etiol- 
ogy. 

2. PARALYSIS AGITANS. (Parkinson's Disease.) 



(Bell's Mania.) 

A disease running a 
rapidly fatal course, as- 
sociated with fever, de- 
lirium and insomnia. 



Abrupt onset, deliri- 
um, fever and fatal ter- 
mination within three 
weeks. 



No constant lesions, 
although the anatomical 
substratum of its occur- 
rence is due to the usual 
lesions of cerebro-spinal 
senility. 



A chronic affection, 
more frequent in men 
than women, and rarely 
occurring before the for- 
tieth year. It is char- 
acterized by muscular 
weakness, tremors and 
rigidity. 



Gait (p. 3), tremor 
when the muscles are at 
repose, weakness and 
rigidity of the muscles, 
expressionless face and 
shrill and piping voice. 



FUNCTIONAL NERVOUS DISEASES, 



215 



FUNCTIONAL NERVOUS DISEASES-Continued. 



Morbid Anatomy, 



General Symptoms. Characteristic Symptoms. 



3. ACUTE CHOREA. 

No constant lesions. 
Emboli in the cerebral 
vessels. Endocarditis is 
believed by some to be 
the cause. 



A disease of children, 
manifested by irregular 

involuntary contractions 
of the muscles. It is 
more frequent in fe- 
males. 



4. INFANTILE CONVULSIONS. (Eclampsia.) 



May occur from debil- 
ity, rickets, peripheral 
irritation, as dentition, 
fever and cerebral con- 
gestion. 



5. EPILEPSY. 

No definite lesion. The 
following causes may be 
cited : heredity, chronic 
alcoholism in the par- 
ents, syphilis and trau- 
ma. 



The convulsive seizure 
resembles that of epi- 
lepsy, but differs from 
the latter, that when the 
cause is removed the 
convulsions do not re- 
cur. 



Attacks of uncon- 
sciousness with or with- 
out convulsions. The 
former is known &s grand 
mat, the latter as petit 
mal. The attacks are 
preceded by a sensation 
known as aura. 



Occurrence in young 
patients of female sex"; 
contractions of muscles 
disappear during sleep ; 
contractions occur inde- 
pendent of the will. 



Convulsions associated 
with a loaded stomach 
or as a prelude to an in- 
fectious disease, in which 
instance it is accompa- 
nied by fever and vomit- 
ing. 



Abrupt loss of con- 
sciousness followed by 
tonic and clonic spasms 
ending in coma. 



6. HEMICRANIA. (Migraine.) 



The nature of the dis- 
ease is not known. It is 
related to epilepsy, and 
consists of a nerve storm 
or periodic discharge 
from sensory centers. 
The early symptoms are 
supposed to be due to 
vaso-constrictor and the 
later symptoms to vaso- 
dilator" influences. 



A paroxysmal affection 
manifested by unilateral 
headache and associated 
with visual and gastric 
disturbances. Women 
and neurotic members 
of a family are predis- 
posed. Nausea and vom- 
iting are frequent symp- 
toms. 



Periodical unilateral 
headache, the patient re- 
maining well during the 
intervals of the attacks. 
Spastic hemierama is as- 
sociated with pallor, and 
paralytic hemicrania with 
redness of the face. 



7. TETANY. 

No lesion. Tetany may 
be : 1, epidemic ; 2, may 
follow lactation or chronic 
diawhea ; 3, after remov- 
al of the thyroid gland ; 
4, it may be associated 
with dilatation of the 
stomach. 



It is manifested by to- 
nic spasms of the ex- 
tremities. The irrita- 
bility of the nerves is 
increased, and pressure 
on a nerve trunk or ar- 
tery will cause a spasm.^ 



See pages 171 and 180. 



216 



MANUAL OF CLINICAL DIAGNOSIS. 



FUNCTIONAL NERVOUS DISEASES-Continued. 



Morbid Anatomy. 



Genu ral Symptoms. 



Characteristic Symptoms. 



8. HYSTERIA. 

There are no anatom- 
ical changes. It is a 
state in which ideas con- 
trol the body and pro- 
duce morbid changes in 
its functions. It is an 
increased excitability of 
the whole nervous sys- 
tem. 



It is a functional dis- 
ease with motor (paraly- 
sis, spasms, convul- 
sions), sensory (anaesthe- 
sia and hyperesthesia, 
etc.), and psychical 
symptoms. 



9. TRAU3IATIC NEUROSIS. (Railway Spine.) 

Symptoms of neurasthe- 
nia: headache, tired feel- 
ing, irritability, numb- 
ness in the extremities, 
disturbed digestion. 



The condition follow- 
ing a shock may present 
the symptoms of neuras- 
thenia or hysteria, or 
both, or may be the re- 
sult of organic disease 
of the brain and cord. 



10. NEURASTHENIA. 

No demonstrable ana- 
tomical lesions. It is a 
weakness or exhaustion 
of the nervous system. 



Symptoms of hystena: 
sensory disturbances, 
tremor and limitation of 
the held of vision. 



According to the clini- 
cal picture : 

Cerebral nenrastheniei : 
depression of spirits, 
vertigo, insomnia, irrita- 
bility and hysterical 
manifestations. 

Spinal neurasthenia: 
pain in the back, weak- 
ness on exertion, and 
local tenderness of the 
spine. 



11. JACKSONIAN EPILEPSY. 



Irritative lesions in the 
motor zone of the cere- 
bral cortex, such as tu- 
mor, softening, menin- 
gitis, abscess and hem- 
orrhage. 

12. ASTASIA ABASIA. 

A neurosis related to 
hysteria. 



Spasms occurring in 
definite muscle groups, 
as the face, arm or leg 
with retention of con- 
sciousness ; as a prelude 
to the spasms there may 
be numbness in the part. 



The patient is unable 
to stand erect or walk 
properly, notwithstand- 
ing muscular strength, 
coordination and sensa- 
tion are intact. 



The symptoms devel- 
op and disappear ab- 
ruptly, are unaccompa- 
nied by general ill- 
health, are intensified or 
inhibited by emotional 
excitement. 



Organic changes are 
indicated by optic atro- 
phy, bladder symptoms, 
tremor and exaggerated 
reflexes. The history of 
a shock preceding the 
S} T mptoms. 



Absence of symptoms 
pointing to organic mis- 
chief. "The diagnosis of 
neurasthenia should on- 
ly be made after an ex- 
clusion by systematic 
examination of organic 
disease. Neurasthenia 
is hysteria occurring in 
man. 



Paroxysmal spasms 
confined to definite mus- 
cle groups with perfect 
consciousness. 



When the patient 
stands, the legs give 
way as if made of cot- 
ton. 



FUNCTIONAL NERVOUS DISEASES. 



817 



FUNCTIONAL NERVOUS DISEASES -Continued. 



Morbid Anatomy, 



Gem ral Symptoms. 



< 'haracteristic Symptoms. 



13, TI< (ONVILsif. (Tourette's Disrase.) 



A neurosis related to 
hysteria and occurring 
usually in young chil- 
dren with a neurotic 

family history. 



14. ATHETOSIS. 

It is usually symptom- 
atic of a cerebral or spi- 
nal affection, or it may 
occur idiopathic ally. 



Involuntary muscular 
movements of the face. 
arm or other groups of 
muscles, accompanied 
by explosive utterances 
in which had language 
is often used (coprolalia). 



Rhythmical move- 

ments of the fingers and 
toes which cannot be 
controlled by the patient, 
and persist without in- 
terruption during wak- 
ing and sleeping. 



Involuntary muscular 
movements, explosive 
utterances and mental 
disturbances. 



Athetosis is usually a 
symptomatic affection. 
r lhe athetoid movements 
continue during sleep 
and are usually uninflu- 
enced by treatment. 



218 



MANUAL OF CLINICAL DIAGNOSIS. 



1 

►^ CO 

Is 

O 
K 
P 
ft 


o3 


o . 
o o 

2 S 
.2 § 

£^ 


Hemiplegia is usually 
on the left side ; the 
face is not affected, 
but the leg suffers 
most. 

Paraplegia is more 
common than the 
former. The loss of 
power is not abso 
lute. 


h-3 

8 


Atrophy of the mus- 
cles independent of 
the nervous system. 
The affection is he- 
reditary, and sets in 
usually before pu- 
berty. 


There may be dimin- 
ished electrical irri- 
tability, but the reac- 
tion of degeneration 
is never present. 


Muscles of the upper 
arm and shoulder, 
gluteal, thigh and 
facial muscles. 


CO 
CO 

n 

Ph 

hI 

g 

H 
O 


Thrombosis, embol- 
ism, abscess, tumors, 
and hemorrhage. 


Electrical irritability 
unchanged, unless 
the cerebral nuclei 
are implicated. 


In cortical lesions 
monoplegia may oc- 
cur; as a rule there 
is hemiplegia. Facial 
paralysis, if present, 
is only partial, in- 
volving the lower 
portion of the nerve. 


h3 

tf to 
1 

s 

Pn 


Trauma, neuritis, 
neuroma, chemical 
and thermic irri- 
tants and infec- 
tious diseases. 


CD 

O 


Limited to the mus- 
cles supplied by 
the affected nerves. 


CO 
OQ 

Ph 

i— i 
PU 
CO 


Myelitis, tumors of 
the cord, compress- 
ion of the cord, he- 
morrhage and trau- 
matism. 


Reaction of degener- 
ation is present in all 
paralyses produced 
by disease of the 
ganglionic cells, in 
the anterior horns of 
the gray matter. 


Hemiplegia, paraple- 
gia, hemi-paraplegia 
and paralysis of spe- 
cial nerve roots. 

Paraplegia is the 
usual form. 




i 

o 
o 

H 


62 

«5 


Distribu- 
tion of 
Paralysis. 



SYNOPTIC TABLE OF PARALYSES. 



21!) 



< 

Ah 

HJ CO 

%i 

o 

•A 
P 

h 


03 

o 

P< . 

2 S 

»! 


Ancesthesia is common 
and usually confined 
to one half the body. 
It is as a rule limited 
to the middle line 
and involves the 
deep parts. 


The reflexes may be 
increased or normal. 


Hysterical symptoms. 
Hysterical paraplegia 

is not attended by 
implication of the 
bladder. 


i 

O CO 

Si 

o 

>-< 

3 


Atrophy in conjunc- 
tion with hypertro- 
phy of the muscles. 
Fibrillary contrac- 
tions are absent. 


There is usually no 
disturbance of sensa- 
tion. 


The tendon reflexes 
are present, but in 
cases where the mus- 
cle atrophy is pro- 
nounced they may 
be reduced. 


The paralysis is al- 
ways proportionate 
to the atrophy. 


CO* 
0Q 

< 

< 

■4 

B 

w 
o 


No degenerative mus- 
cular atrophy, not- 
withstanding long 
continuance of the 
paralysis. 


Hemianaesthesia may 
be present, especially 
if the lesion is in the 
internal capsule. 
There may be no 
sensory disturbances. 


The deep reflexes are 
increased on the par- 
alyzed side, and an- 
kle clonus may be 
present. The sphinc- 
ters are not affected. 


Psychical disturb- 
ances, headache, dis- 
turbances of vision 
and hearing, ophthal- 
moscopic changes, 
vertigo and aphasia. 


>-3 CO* 

a 


CO 

Ph£ 

<-4* 


In a mixed nerve, 
ancesthesia limited 
to the distribution 
of the nerve. 


Absent, if the reflex 
circuit is destroyed 
by the nerve lesion. 


Absence of cerebral 
and spinal symp- 
toms. 


CO* 
CO 

« 

id 

g 

s 

CO 


Atrophy of the mus- 
cles, when the cells 
of the anterior horn 
are affected, or when 
the anterior nerve 
roots are separated 
from their trophic 
center. 


Disturbances of sen- 
sation are common, 
especially if the pos- 
terior nerve roots are 
implicated. 


In implication of the 
lateral column, the 
reflexes are increased, 
otherwise they are 
usually diminished 
or absent. 


Girdle sensations, im- 
pairment of the blad- 
der or rectum. 




Condition 

OF THE 

Muscles. 


Disturb- 
ances of 
Sensation. 


CO* 

H 

N 

H 

a 


Concur- 
rent Symp- 
toms. 



220 



MANUAL OF CLINICAL DIAGNOSIS. 



VASO-MOTOR AND TROPHIC DISEASES. 



Morbid Anatomy. 



General Symptoms. 



Character id ic Symptoms. 



1. RAYNAUD'S DISEASE. (Symmetrical Gangrene.) 



A vascular affection 
characterized by various 
grades of intensity, viz. : 
l. Local syncope ; 2. Lo- 
cal asphyxia ; 3. Local 
gangrene. The first is 
produced by contraction 
of the blood-vessels, and 
the second by dilatation 
of the capillaries and 
small veins. 



Syncope. The fingers 
or toes look like dead. 

Asphyxia. The toes or 
fingers are livid, swollen 
and painful. The dis- 
ease is usually confined 
to the extremities. 



The affection is usually 
symmetrical, and hemo- 
globinuria is not uncom- 
mon during an attack. 



3, ANGIO-NEUROTIC OEDEMA. 



A neurosis with an 
hereditary tendency, and 
caused by vaso-motor di- 
latation of the blood-ves- 
sels with transudation of 
serum. 



(Edematous swelling 
appearing in various 
parts of the bod} 7 , par- 
ticularly in the face and 
hands. 



(Edema is circum- 
scribed and appears sud- 
denly attended by gas- 
tro-intestinal distress. 



3. ACROMEGALIA. (Marie's Disease.) 



Hypertrophy of the 
bones and pituitary 
body, and persistence of 
the thymus gland. 



A dystrophy charac- 
terized by increased 
growth of the bones of 
the face and extremities 
and overlying tissues. 



4. FACIAL HEMIATROPHY. 



Interstitial neuritis of 
the trigeminus nerve. 
The nature of the dis- 
ease is doubtful. 



Progressive wasting of 
the bones and soft tis- 
sues of one side of the 
face. It usually devel- 
ops in childhood. 



Egg-shaped face with 
the large end downward, 
dullness over the manu- 
brium sterni due to per- 
sistence or enlargement 
of the thymus gland. 



The affected side is 
sunken, and the skin 
shows a whitish-brown 
discoloration. 



EXOPHTHALMIC GOITRE. 



Nothing definite. En- 
largement and thicken- 
ing of the cervical sym- 
pathetic ganglia have 
been observed. 



A disease of early 
adult life, frequent in 
females and character- 
ized b} 7 palpitation of the 
heart, protrusion of the 
eye -balls, and enlarge- 
ment of the thyroid 
gland. 



See page 181. One of 
three important symp- 
toms may be absent. 
Tremor may be present 
and shows a great regu- 
larity of rhythm. 



DISEASES OF THE MUSCLES. 



221 



VASO-MOTOR AND TROPHIC DISEASES-Continued. 



Morbid Anatomy. 



General Symptoms. 



( Characteristic Symptoms. 



(». MVX(E1)E>IA. 

Mucoid degeneration 
of tlu i subcutaneous tis- 
sues, and atrophy of the 
thyroid gland. 



A constitutional dis- 
ease, more frequent in 
women than in men, and 
marked by swelling in 
the face and upper ex- 
tremities, mental failure 
and dementia. 



The swelling does not 
pit on pressure. Feat- 
ures arc coarse, and over 
the cheeks there is a red- 
dish patch. Tempera- 
ture is subnormal, and 
there is atrophy of the 
thyroid gland. 



7. SUNSTROKE. (Thermic Fever.) 



Early rigor mortis, 
congestion of the brain 
and lungs, and paren- 
chymatous changes in 
the liver and kidneys. 



After exposure to high 
temperatures, exhaus- 
tion, vertigo, nausea and 
headache followed by 
coma, hyperpyretic tem- 
perature with full and 
rapid pulse. 



The mode of onset and 
high temperature ena- 
bles the coma to be dif- 
ferentiated from apo- 
plexy, alcoholism, etc. 



DISEASES OF THE MUSCLES. 



1. IDIOPATHIC MUSCULAR ATROPHY. 



Muscular wasting with 
or without initial hyper- 
trophy, and occurring 
independently of the 
nervous system. 



An hereditary disease 
of progressive character, 
presenting two chief 
types : 1, primary hyper- 
trophy ; and 2, primary 
atrophy. 



The primary myopa- 
thies involve the muscles 
of the calves, trunk, face 
or shoulder girdle. They 
occur usually before pu- 
berty. (See pseudo-hy- 
pertrophic paralysis). 



2. MYOTONIA CONGENITA. (Tliomsen's Disease.) 



The nature of the af- An hereditary disease 
fection is unknown. The characterized by tonic 
muscular fibres of the cramp or spasm of the 
voluntary muscles are muscles on attempted 
increased in width. movement. The affec- 

tion first appears in 
childhood. 



Muscular spasms on 
attempting voluntary 
movements. The sensa- 
tion and reflexes are nor- 
mal. Myotonic reaction 
(on galvanic stimulation 
of the muscles, the con- 
tractures are slow and 
prolonged, lasting as 
long as thirty seconds). 



222 MANUAL OF CLINICAL DIAGNOSIS. 

DISEASES OF THE MUSCLES— Continued. 



Morbid Anatomy. 



General Symptoms. 



Characteristic Symptoms. 



3. PARAMYOCLONUS MULTIPLEX. 



The nature of the dis- 
ease is unknown, al- 
though it may be regard- 
ed as an emotional neu- 
rosis of hysterical origin. 



Clonic muscular 
spasms in the muscles 
of the face and extrem- 
ities, usually symmetri- 
cal and appearing in par- 
oxysms. The strength 
of the muscles and elec- 
trical excitability re- 
main unaltered. 



Clonic contractions of 
the muscles unaccompa- 
nied by sensory or motor 
disturbances. 



4. GRAPHOSPASM. (Writers' Cramp.) 



There are no anatomical 
changes. It results from 
a deranged action of the 
nerve centers presiding 
over the muscles in- 
volved in writing. 



Spastk form. Clonic 
or tonic spasm when the 
pen is grasped. 

Tremulous form. Tre- 
mor when the muscles 
are used. 

Paralytic form. Weak- 
ness and fatigue of the 
muscles. 



Sensory and vaso-mo- 
tor disturbances asso- 
ciated either with spasm, 
paresis, paralysis or tre- 
mor of the muscles em- 
ployed in writing. 



PSEUDO-HYPERTROPHIC PARALYSIS. 

tropliy.) 



(Pseudo-Muscular Hyper- 



There is no lesion of 
the nervous system. It 
is a primary affection of 
the muscles character- 
ized by an excess of fat 
and connective tissue 
between the muscular fi- 
bres, and degenerative 
atrophy of the latter. 



A disease of childhood 
manifested by enlarge- 
ment of the muscles of 
the calf, thigh, buttock 
or back, and muscular 
weakness without senso- 
ry disturbances. The 
prognosis is unfavora- 
ble. 



Gait (page 3). Enlarge- 
ment of the muscles with 
weakness of the latter, 
and absence of the re- 
action of degeneration. 



VESICULAR INFLAMMATIONS OF TUE SKIN. 



223 



DIAGNOSIS OF DISEASES OF THE SKIN. 



ERYTHEMATOUS INFLAMMATIONS OF THE SKIN. 



Site of Predilection. 



General Character of the 
Eruption. 



Characteristic Signs. 



1. ERYTHEMA NODOSUM. 



The extremities partic- 
ularly the lower. 



Bright red nodes vary- 
ing in size from a pea to 
an egg. 



3. ERYTHEMA MULTIFORME. 



The extremities. 



The cutaneous lesions 
change frequently, and 
may consist of macules, 
papules, vesicles, or bul- 
lae. 



3. URTICARIA. (Hives.) 



The wheals occur 
mostly on the face and 
trunk, although other 
parts of the body are not 
exempt. 



An inflammatory affec- 
tion attended by the 
eruption of pale red, 
evanescent wheals. 



Eruption accompanied 
by febrile disturbances. 
Nodes change color like 
a bruise. 



The variety of the le- 
sions. 



Suddenness and short 
duration of eruption as- 
sociated with intense 
itching. 



VESICULAR INFLAMMATIONS OF THE SKIN. 



1. HERPES ZOSTER. (Shingles.) 



Follows the distribu- 
tion of the nerves. 



Groups of small vesi- 
cles on inflammatory 
bases accompanied with 
neuralgia. 



2. MILIARIA. (Prickly Heat.) 



On covered parts 
(breast, abdomen, ex- 
tremities, etc.). 



3. ECZEMA. (Tetter.) 

The skin of any part of 
the body, with predilec- 
tion for the face, genita- 
lia, hands and feet. 



An inflammatory dis- 
ease of the sweat glands, 
attended by a discrete 
eruption of minute vesi- 
cles. 



A non-contagious af- 
fection with multiform 
lesions (erythema, papu- 
les, vesicles, pustules, 
scales and crusts). 



Grouping of vesicles 
and their relation to the 
nerves. 



Lesions are discrete 
and attended with burn- 
ing, itching and perspir- 
ation. 



Multiform skin lesions, 
itching and discharge. 



224 



MANUAL OF CLINICAL DIAGNOSIS. 



BULLOUS INFLAMMATION OF THE SKIN. 



Site of Predilection. 



General Character of the 
Eruption. 



Characteristic Signs. 



1. PE3IPHIGUS. 

May attack the skin or 
mucous membranes in 
any part of the body. 



Characterized by the 
eruption of successive 
crops of bullae or blebs. 
Bulla? are elevations of 
the skin containing se- 
rous fluid, and varying 
in size from a pea to an 
egg or an apple. 



Acute pemphigus is an 
infectious disease, oc- 
curring in the new born. 

P. foUaceus is a fatal 
disease, characterized by 
bursting of the bullae 
and the formation of 
thick crusts. 



PUSTULAR INFLAMMATIONS OF THE SKIN. 



1. IMPETIGO. 

On the face and ex- 
tremities. 



Eruption of discrete 
pustules varying in size 
from a pea to a cherry, 
and commonly observed 
in children. 



2. IMPETIGO CONTAGIOSA. 

On the face and ex- 
tremities. 



An acute contagious 
disease, occurring in de- 
bilitated children. The 
pustules are flat or um- 
bilicated. 



3. ACNE. 

The face and back. 



4. ACNE ROSACEA. 

On the face, especially 
the nose, cheeks, chin, 
etc. 



Inflammatory disease 
of the sebaceous glands, 
characterized by pap- 
ules and pustules, and 
associated with come- 
dones. 



Acne lesions associ- 
ated with dilatation of 
the blood-vessels and tis- 
sue hypertrophy. 



5. ACNE MENTAGRA. (Simple Sycosis.) 



Beard, eye-brows, and, 
rarely, the hair follicles 
of the head. 



A chronic inflamma- 
tion of the hair follicles, 
leading to tubercles, pus- 
tules, crusts and diffused 
infiltration of the skin. 



Discrete pustular erup- 
tion which dries in a few 
days, leaving thin yel- 
lowish crusts, which drop 
off and leave a normal 
surface. 



The yellowish crusts 
when they drop off leave 
behind an excoriated 
surface. 



Chronic character of 
the affection and impli- 
cation of the sebaceous 
glands. 



Acne lesions, dilata- 
tion of the vessels and 
overgrowth of tissue. 



Inflammation is super- 
ficial, the hairs are not 
involved, and the trico- 
plujton is absent. 



PAPULAR INFLAMMATIONS OF TUE SKIN. 



22r> 



PUSTULAR INFLAMMATIONS OF THE SKIN-Continued. 



Site qf Predilection. 



i liarader of the 



Vharactt ristic Signs. 



6. TINEA SYCOSIS. (Barber's Itch.) 



Bearded region. 



Like the foregoing. 
The hairs become lustre- 
less, brittle and loose. 

If involved hairs are al- 
lowed to remain for fif- 
teen minutes in a solu- 
tion of caustic potash 
(1 : 3), the spores and 
threads of the tricophy- 
ton tonsurans can be seen. 



Inflammation is deep, 
the hairs an- involved, 

and the trichophyton ean 
be demonstrated. 



SCALY INFLAMMATIONS OF THE SKIN. 



1. PSORIASIS. 

Extensor surfaces of 
the knees and elbows, 
hair of the head and ears. 
The lesions may ap- 
pear on any part of the 
body. 



A chronic inflamma- 
tion leading to the de- 
velopment of pearly 
scales which, when de- 
tached, leave behind a 
red or bleeding surface. 
Itching is slight or ab- 
sent. 



2. PITYRIASIS RUBRA. 



Usually diffused over 
the body. 



A rare disease of 
chronic duration, attend- 
ed by tension and con- 
traction of the skin, fe- 
ver and the development 
of red spots which scale. 



Predilection for the 
extensor surfaces, dry 
pearly scales, absence 
of itching, protracted 
course and tendency to 
relapse. 



Fever attends the de- 
velopment of the erup- 
tion. The disease leads 
to marasmus. 



PAPULAR INFLAMMATIONS OF THE SKIN. 



1. PRURIGO. 

The back and extensor 
surfaces of the extremi- 
ties. 



A chronic disease at- 
tended by an eruption of 
small, discrete, pale red 
papules and itching. De- 
velops in early "child- 
hood, and persists 
through life. 



The development in 
early childhood, charac- 
ter of the eruption and 
intense itching. 



226 



MANUAL OF CLINICAL DIAGNOSIS. 



PAPULAR INFLAMMATIONS OF THE SKIN-Continued. 



Site of Predilection. 



General Character* of tfie 
Eruption. 



Characteristic Signs. 



2. LICHEN EUBER. 

Breast, abdomen, geni- 
talia and flexor surfaces 
of the extremities. 



A chronic disease oc- 
curring in middle-aged 
males, characterized by 
the development of small 
red papules, itching and 
failure of health. 



3. LICHEN SCROFULOSIS. 

Back, breast, lower 
part of abdomen, and 
later the flexor surfaces 
of the extremities. 



A chronic disease, oc- 
curring in children of a 
strumous diathesis, at- 
tended by sma 11 pale red 
papules. 



Itching, failure of the 
general health, and its 
occurrence in poorly 
nourished middle-aged 
individuals. 



Absence of itching, 
scrofulosis, pale skin, 
and occurrence in chil- 
dren. 



HYPERTROPHY OF THE SKIN. 



1. ICHTHYOSIS. (Fish Skin Disease.) 



Extensor surface of 
the extremities. May in- 
volve the skin over the 
entire body, excepting 
the flexor surfaces of the 
joints, genitalia, palms 
and soles. 

2. SCLERODERMA. 

Upper half of the body, 
although it may be dif- 
fused. 



A chronic affection 
manifested by dryness, 
thickening of the epi- 
dermis and scaliness. It 
is first detected in early 
childhood, and is an in- 
curable disease. 



. ELEPHANTIASIS. 

Legs and genitals. 



A chronic affection 
leading to induration of 
the skin in patches, or 
involving the entire 
body. Death occurs 
usually from marasmus. 

Hypertrophy of the 
skin and subcutaneous 
tissues, leading to enor- 
mous enlargement. 

4. CHELOID. (Keloid.) 

Chest and back. Hypertrophy of the 

skin, beginning as a pale 
red nodule, which sends 
out claw-like processes, 
making it resemble a 
crab. It returns after 
removal. 



Absence of inflamma- 
tory symptoms, chron- 
icity and detection in 
early childhood. 



Induration of the skin, 
which renders the parts 
immobile. 



Thickening of the skin 
and subcutaneous tis- 
sues, associated with 
lymphangitis. 

Occurs frequently in 
the colored race, history 
of heredity. It is dis- 
tinguished from a scar 
by the fact that the lat- 
ter does not extend be- 
yond the injury. 



PABASITES OF THE SKIN. 



227 



ATROPHY OF THE PIGMENT OF THE SKIN. 



Site of Predilection. 



General Character of the 

Kniption. 



Characteristic Signs. 



1. VITILIGO. (Leucoderma.) 



On parts of the body 
exposed to injuries and 
pressure. 



An acquired affection 
characterized by milk- 
white patches surround- 
ed by areas of increased 
pigmentation. 



Aside from the absence 
of pigment, the skin is 
normal. 



NEUROSIS OF THE SKIN. 



1. PRURITUS, 

Any part of the body. 



A functional affection 
independent of any ana- 
tomical changes in the 
skin. 



Itching and the ab- 
sence of any definite skin 
lesions, unless they are 
the result of scratching. 



PARASITES OF THE SKIN. 



1. SCABIES. (Itch.) 

Between the fingers, 
wrists, axilla?, genitals, 
and beneath the mammae. 
The face and scalp are 
never implicated. 



A contagious disease 
caused by the Acarus 
Scabiei, and manifested 
by the development of 
papules, vesicles, pus- 
tules and burrows. 



The itching is intense, 
history and sites of pre- 
dilection. For demon- 
stration of the acarus, 
see p. 189. 



2. TINEA TRICOPHYTINA. (Ringworm.) 

Tinea Tonsurans: char- 
acterized by scaly, ele- 
vated patches, through 
which dry, brittle hairs 
project. 

Tinea Circinaia: scaly 
patches which clear up 
in the center. 



Ringworm occurring 
on the scalp is known as 
Tinea Tonsurans; on the 

body, Tinea Circinata: on 
the heard, Tinea Sycosis. 



Itching and demon- 
stration of the tricophy- 
ton, see p. 190. 



3. TINEA VERSICOLOR. (Pityriasis Versicolor.) 



Chest and back. It 
may occur on the face, 
though rarely. 



Salmon colored, yel- 
lowish or dark-brown 
spots, generally scaly, 
caused by the microspo- 
ron furfur. 



Scaly pigmented spots 
and demonstration of the 
microsporon, see p. 190. 



228 



MANUAL OF CLINICAL DIAGNOSIS. 



PARASITES OF THE SKIN-Continued. 



Site of Predilection. 



General Character of the 
Eruption. 



4. PHTHEIRIASIS. (Pediculosis.) 



PedkuLus capitis ; lice 
confined to the scalp. 

Pedicvlus corporis; body 
or clothes lice. 

lUlicuhis pubis ; crab 
louse confined to pnbes, 
axillae, etc. 



Eczematous lesions 
and scratch marks 
caused by the intense 
itching ; petechia? caused 
by the bite of the insect. 



5. TINEA FAVOSA. (Favus.) 



The scalp. It rarely 
affects the nail substance 
(on ych oi i \ ycosis favosa) . 



A contagious scalp af- 
fection manifested by 
yellowish, cup-shaped 
crusts, through which 
dry, brittle, lustreless 
hairs project. The crusts 
have a peculiar musty 
odor. 



Characteristic Sign %. 



Demonstration of the 
ova or nits and the lice. 
See page 189. 



Yellow, cup-shaped 
crusts, odor and demon- 
stration of the fungus, 
Achorion Schoenleinii, see 
page 190. 



DRUG EXANTHEMATA. 

Quinine, morphine, opium, atropine, digitalis, chloral 
hydrate, antipyrine, plienacetine, sulphonal and strychnine, 
often produce an eruption of an erythematous character. 

After the use of the salicylates a bullous eruption has been 
observed. 

Arsenic may produce an itching papular or vesicular 
eruption. 

Copaiba and Turpentine, produce an urticaria-like erup- 
tion. 

Iodides and bromides produce an acne eruption. 



BACTERIOLOGICAL DIAGNOSIS. 



BACTERIOLOGICAL DIAGNOSIS. 



PATHOGENIC MICROBES. 



■ nul Arrangement. 



Growth. 



Reaction. 



1. ACTINOMYCOSIS. (Kay Fungus.) 



Cultures obtained af- 
ter five to six days on 
agar-agar and gelatine 
without liquefaction. 



Found in man and cat- 
tle as a round, flattened. 
hollow body, with a cen- 
tral cavity made up of 
club-shaped elements in 
th e form of a ro s e tt e . In 
the pus or scrapings, lit- 
tle yellow grains "about 
the size of a pin's head 
are seen containing the 
ray fungus. 

2. ANTHRAX BACILLUS. (Bacillus Anthracis.) 



Cover glass prepara- 
tions are best stained by 
Gram's method. (See 
page 193.) 



Found in the blood 
and organs of animals 
afflicted with splenic fe- 
ver. The bacilli are rods 
with broad cup-shaped 
ends. In cultures long 
threads are formed with 
large oval spores. 

3. CHOLERA BACIIXUS. (Comma Bacillus.) 



Grows rapidly between 
1*2° and 45° C, and re- 
quires plenty of oxygen. 
Colonies develop in two 
days on gelatine plates. 



Found in the intestinal 
canal and faeces of chol- 
era patients. It is a 
curved bacillus about 
half the size of a tuber- 
cle bacillus. Discovered 
by Koch in 1884. 



Develops at ordinary 
temperatures on all nu- 
trient media that have 
an alkaline or neutral re- 
action. In a solution of 
peptone at 37° C, they 
develop rapidly on the 
surface in six to twelve 
hours. 



They take the aniline 
dyes. To bring out the 
cup-shaped ends, methy- 
lene blue is best. 



It is best colored with 
aqueous solution of fuch- 
sin, and may be decolor- 
ized by Gram's method. 
For color reaction, see 
page 123. 



4. DIPHTHERIA BACILLUS. (Bacillus Diphtheria-.) 



Found in diphtheritic 
membranes. Straight or 
crooked rods, the same 
length as the tubercle 
bacilli, but twice as thick. 
They stain most intense 
at the ends. 



They grow on pepto- 
nized meat-sugar-serum 



After Loffler's meth- 
od : few minutes in a 



infusion at 37° C. They concentrated alcoholic 
grow readily on all me- solution of methylene 
dia between 20° C. and blue, to which has been 



40° C. 



added a KHO solution 
(1 to 10,000), then in 
one-half per cent acetic 
acid, then absolute alco- 
hol, mount in balsam. 



230 



MANUAL OF CLINICAL DIAGNOSIS. 



PATHOGENIC MICROBES-Continued. 



Form and Arrangement. 



Growth. 



Reaction. 



5. GONORRHEA. (Gonococcus.) 



Found in the secre- 
tions of gonorrhoic in- 
flammation as cocci, al- 
ways in pairs (diplococcus i, 
biscuit-shaped, with flat 
surfaces lying together 
resembling the coffee- 
bean. 

6. LEPROSY. (Lepra Bacillus.) 



Growth doubtful. Only 
upon human blood se- 
rum have they given auy 
semblance of growth. 



Found in all leprous 
products. Small rods, 
shorter than tubercle 
bacilli, with occasionally 
pointed ends. 



7. BACILLUS MALLEI 

Found in the nodules 
of the disease. Small 
rods about the size of 
the tubercle bacillus. 
The ends are rounded. 
They appear singly as a 
rule". 



Grows on blood serum 
to which peptone and 
glycerine have been 
added. Growth slow and 
requires about eight days 
at a temperature of 
37° C. 

. (Glanders.) 

Grow abundantly on 
glycerine-agar or blood 
serum at 3f° C. 



Best stained with fuch- 
sin or methyl-violet. It 
is not discolored by 
Gram's method. 



Same reaction as tu- 
bercle bacillus (see page 
65), but stain more quick- 
ly. They do not stain in 
LCffier's alkaline methyl 
blue solution, thus dif- 
fering from the tubercle 
bacillus. 

Gram's method is not 
applicable. Loffler's me- 
thylene blue is the best 

stain. 



8. 31 AL ARIA. (Plasm 

Found in the blood 
corpuscles of malarial 
patients. They are pro- 
toplasmic corpuscles of 
various forms (round, 
oval, crescentic and fla- 
gella). They may or 
may not contain black 
pigment. They show 
rapid amoeboid move- 
ments. 

9. PNEUMONIA. (Bacillus Pneumonia?.) (Diplococcus Pneumoniae.) 



odium Z>Ialariae.) 

They have not been 

cultivated. Inoculations 
with the blood of a 
malarial patient will pro- 
duce a typical attack of 
malaria fin another per- 
son. They disappear 
from the blood after the 
use of quinine. 



The organisms are best 
observed when the blood 
is fresh and unstained. 
A powerful lens is neces- 
sary. Dried specimens 
of blood may be stained 
with methylene blue. 



Both forms have been 
found in pneumonia. 
The bacilli are oval- 
shaped rods nearly as 
wide as they are long. 
In tissues each bacillus 
has a faint capsule. The 
diplococci are rod-shaped, 
longer than broad, usu- 
ally^ in pairs, and sur- 
rounded by a capsule. 



The bacilli grow rapid- 
idly on all media. The 
diplococci grow slowly 
on alkaline media. 



Stained by Friedland- 
er's method (page 67), 
although the ordinary 
aniline stains will suffice. 



BACTERIOLOGICAL DIAGNOSIS. 



231 



PATHOGENIC MICROBES— Continued. 



Form and Arrangement. 



Growth. 



liraction. 



10. RELAPSING FEVER. (Spirillum or Spirochete Obermaierl.) 



Found in the blood of 
relapsing or recurrent 

fever. "The organisms 
are long spiral "threads 
with a distinct flagellum, 
and tlu\y move by means 
of wavy undulations. 
They are only found in 
the blood during the 
fever. 



They have not been Ordinary aniline stains, 
cultivated. After fixing in the flame, 

cleanse with a four per 
centacetic aeid solution 
and stain with the ordi- 
nary aniline solutions. 



11. SUPPURATOIN. (Streptococcus Pyogenes.) 
genes Anreus.) 



Found in pus. They 
produce suppuration. 
The streptococci are coc- 
ci found singly and in 
chain-like groups. The 
staphylococci are micro- 
cocci in clusters like 
bunched grapes. 



The streptococci grow 
in bouillon and the sta- 
phylococci on gelatine. 



(Staphylococcus Pyo- 



Ordinary stains 
Gram's method. 



and 



12. STREPTOCOCCUS ERYSIPELATIS. 



Found in the lymph 
channels of the skin in 
erysipelas as very small 
cocci in pairs or chains. 



Grows on gelatine, agar- 
agar and blood serum at 
a temperature from 30° C. 
to 37° C. 



Retains color 
Gram's method. 



after 



13. SYPHILIS. (Bacillus Syphilis.) 



A bacillus found in 
the tissues and secre- 
tions of syphilis. In size 
and shape it resembles 
the tubercle bacillus. It 
is frequently curved, and 
has clubbed ends. 



Has 
vated. 



not been culti- 



Stain in fuchsin solu- 
tion for twenty-four 
hours, rinse in water, 
then in a chloride of iron 
solution, then alcohol, 
and clear in clove oil. 



14. TETANUS. (Tetanus Bacillus.) 



Found in the earth and 
in the secretions from 
the wounds of tetanus 
patients. They are fine 
bacilli, and form threads 
in irregular masses. 



Develops slowly and 
only when oxygen is ex- 
cluded. Grows in nearly 
all the media. 



Colors with all the or- 
dinary aniline dyes, and 
Gram's method. 



232 



MANUAL OF CLINICAL DIAGNOSIS. 



PATHOGENIC MICROBES -Continued. 



Form and Arrangement. 



Growth. 



Jo action. 



15. TUBERCULOSIS. (Bacillus Tuberculosis.) 



Found in the products 
of human and animal tu- 
berculosis as thin rods, 
one-fourth to one-half 
the diameter of a red 
blood corpuscle in 
Length, beaded and with 
rounded ends. 



Grows in gryeerine 
agar-agar, on potatoes 
and blood serum. They 
grow slowly, and are 
only visible after ten to 
fifteen days. 



16. TYPHOID FEVER. (Bacillus Typhosus.) 



Found in the blood, 
urine, faeces and tissues 
of typhoid patients as 
bacilli, three times as 
long as they are broad, 
with rounded ends. 



They grow slowly on 
all nutrient media. 



See page 65. 



They take the aniline 
dyes less deeply than 
other bacilli. Not col- 
ored by Gram's method. 



BACTERIOLOGICAL ANALECTS. 



1. The diagnostic value of the iyplioid bacilli when 
found in the stools is questionable, as it is almost impossible 
to differentiate them from the bacterium coli commune which 
is also present. Puncture of the spleen for the purpose of 
obtaining cultures of the typhoid bacilli is a procedure not 
always free from danger. 

2. Typhoid bacilli retain their vitality for weeks in 
water. They thrive in the soil and are not killed by 
freezing. 

3. The spirilla of relapsing fever are met with in the 
blood only during the paroxysms of fever, and disappear in 
the intervals. Their number is not proportionate to the 
severity of the attack. The spirilla are absent in the secre- 
tions. 



BACTERIOLOGICAL ANALECTS. 233 

4. The streptococci of erysipelas are found in the periph- 
eral parts of the erysipelatoid inflammation, and almost 
exclusively in the lymphatic vessels. 

5. The incubatory period of inoculated erysipelas is from 
fifteen to sixty hours. 

6. The bacilli of cholera Asiatica occurs only in the stools, 
and never in the blood, of cholera patients. 

7. The bacilli of cholera nostras, which resemble the 
bacilli of Asiatic cholera, are distinguished from the latter 
by being plumper and larger. 

8. The bacillus diphtheria? lies in the surface of diph- 
theritic pseudo-membranes, and is never found in the blood 
or viscera. Cover glass specimens may be made from the 
membrane. 

9. The plasmodium malarice may be found in the blood in 
the following forms : 1. An unpigmented hyaline body within 
the red blood corpuscles, which shows active movements. 
2. A pigmented amoeboid body inside the red corpuscle. 3. A 
segmenting body inside the red corpuscle. 4. Crescentic 
bodies within the red corpuscles. 5. Flagellate organisms. 

10. The anaemia of malaria is caused by a destruction of the 
red blood corpuscles by the plasmodia. 

11. In empyema an examination of the aspirated fluid is of 
great importance. If the pneumococcus is present, the case 
will progress favorably ; if the pus microbes, staphyococci and 
streptococci are present, the empyema is of septic origin and 
the prognosis is exceedingly bad. If the fluid contains no 
organisms, it is, as a rule, of tuberculous origin. 

12. The diplococcus pneumonicc of Fraenkel is the most 
constant organism in croupous pneumonia, although found 



234 MANUAL OF CLINICAL DIAGNOSIS. 

in the buccal secretion in twenty per cent, of healthy indi- 
viduals. 

13. In the secondary affections of pneumonia, such as pleu- 
risy, meningitis, etc., the diplococcus pneumonia is almost 
constantly present. 

14. It is difficult to distinguish the bacillus of syphilis from 
the smegma bacillus, which is found beneath the prepuce. 

15. The bacillus leprce has been cultivated successfully, but 
inoculation experiments on animals have been unsuccessful. 

16. The anthrax bacilli die rapidly under unfavorable con- 
ditions, while the spores possess a high power of resistance. 

17. Anthrax in the human being occurs by inoculation 
through the skin in which case the disease is usually local 
{malignant pustule) ; through the lungs as in the wool sorter's 
disease {pulmonic anthrax), and finally through the intestinal 
canal by the reception of the virus mixed with food or water. 

18. Malignant oedema is caused by a bacillus. It occurs in 
connection with compound fractures, deep wounds, and after 
hypodermatic injections. It is manifested by emphysema of the 
skin, putrefaction and oedematous softening of the muscles 
adjacent to the injury, and finally death. 

19. The tubercle bacillus was discovered by Koch on the 
24th of March, 1882. It is an anaerobic (living without air) 
bacterium. The transmission of tuberculosis is chiefly through 
the lungs. 

20. If in doubt regarding the diagnosis of glanders, inocu- 
lation can be conducted on mice or guinea pigs. Ulcers form 
at the point of inoculation, followed by nodules, which 
caseate. 



Diseases of intestines and peritoneum. 235 



DISEASES OF THE INTESTINES AND 
PERITONEUM. 



Etiology. 



Pathology. 



Symptoms. 



1. APPENDICITIS. 

Occurs in young per- 
sons. More than fifty per 
cent, of the cases oc- 
cur before the twentieth 
year. Foecal masses and 
foreign bodies in the ap- 
pendix play the most im- 
portant etiological role. 
Traumatism is also a fac- 
tor. 



Inflammation of the 
appendix may be catar- 
rhal or ulcerative with 
perforation. Faecal con- 
cretions or enteroliths 
may be present in the 
appendix. Adhesions, 
peritonitis and abscess 
are sequences. 



2. CHOLERA INFANTUM. 



Prevails in hot weather 
and in artificially fed 
children. Faulty feed- 
ing and bad hygiene are 
predisposing factors. 



An infantile disease of 
bacteritic origin (no spe- 
cific microbe has been 
found), with inflamma- 
tion of the mucosa of the 
stomach and intestines. 



3. CHOLERA MORBUS. (Cholera Nostras.) 



An acute sporadic dis- 
ease. Changes in tem- 
perature, summer season 
and unripe fruit are the 
essential etiological fac- 
tors. 

4. CONSTIPATION. 

Sedentary habits, atony 
of the intestines from 
local or constitutional 
causes, weakness of the 
abdominal muscles, etc. 



5. DIARRHOEA. 

Changes of tempera- 
ture, ptomaines and irri- 
tating food in the intes- 
tines, bacteria, poisons, 
reflex disturbances, etc. 



A ptomaine or a spe- 
cific bacillus may be re- 
sponsible for the gastro- 
enteric catarrh. 



The chief local cause 
is atony of the sigmoid 
flexure which forces the 
fasces into the rectum. 



Catarrh of the intes- 
tines. 



Sudden pain in the 
right iliac fossa, attended 
with fever, and local ten- 
derness with or without 
fever. McBurney's point 
(page 118). If general 
peritonitis occurs, it is 
recognized by sudden 
abdominal pain, tympa- 
nites, increased fever 
and rapidity of the pulse. 

Vomiting, frequent 
watery discharge, high 
temperature (105° to 
108° F.), rapid pulse and 
collapse symptoms. 



A sporadic affection, 
characterized by vomit- 
ing, bilious purging, 
moderate fever and great 
prostration. 



No special symptoms. 
Many symptoms of an 
indefinite nature have 
been noted as a result of 
the resorption of noxious 
matter (copramiia) and 
chlorosis is attributed 
to faecal poisoning. 



Frequent passages. In 
memfoanous ente?'itis ^there 
are false membranes or 
mucous easts in the 
stools. 



236 



MANUAL OF CLINICAL DIAGNOSIS. 



DISEASES OF INTESTINES AND PERITONEUM— Continued. 



Etiology. 



Pathology. 



Symptoms. 



6. DILATATION OF THE COLON. 

A congenital condi- Dilatation of the sig- 
tion, or it may result moid flexure occurs, 
from over-distension when it is congenitally 
from faecal accumula- long. An acute dilata- 
tions, tion may follow a twist 
in the mesocolon. 



7. DYSENTERY. (Bloody Flux.) 



Bad hygiene, cachectic 
conditions, exposure to 
cold, irritating food, etc. 
In the tropics, as well as 
in cold climates, the dis- 
ease is produced by the 
amoeba coll. See page 184. 

8. ENTERO-COLITIS. 

Bad food and hygiene, 
and climatic conditions 
are predisposing ele- 
ments. 



9. ENTEROPTOSIS. 



Dilatation of the stom- 
ach and mobility of the 
kidney are frequently as- 
sociated with this condi- 
tion. 



Prolapse of the ab- 
dominal viscera, espe- 
cially the transverse co- 
lon. When all the vis- 
cera fall down the condi- 
tion is called splanchno- 
ptosis. 

10. INTESTINAL COLIC, (Enteralgia.) 
As a symptom it occurs A functional affection 

in plumbism, intestinal caused by spasmodic 



obstruction and inflam 
mation. It may be pro- 
duced by flatulence, fae- 
cal accumulation or irri- 
tating food. 
11. INTESTINAL ULCERS 



contraction of the intes- 
tines. 



Ulcers may be specific 
from syphilis, tubercu- 
losis or typhoid fever. 
Ulceration may also arise 
from the various forms 
of intestinal inflamma- 
tion and pressure of fas- 
ces {stercoral ulcers). 



The duodenal ulcer is 
of peptic origin, like the 
round ulcer of stomach. 
The site of tuberculous 
and typhoid ulcers is the 
ileum, while the ulcers 
of dysentery are located 
in the larse "intestine. 



Tympanitic distension 
of the abdomen. If the 
walls of the colon are 
hypertrophied, the colon 
may be felt. If disten- 
sion of the colon is pro- 
nounced, it may press on 
the diaphragm and inter- 
fere with the heart. 



The inflammation of the 
colon may be catarrhal, 
diphtheritic or amoebic. In 
connection with the lat- 
ter form, abscess of the 
liver is a frequent se- 
quela. 



Inflammation of the 
mucous membrane of 
the ileum and colon. 
The solitary and agmi- 
nated glands are involved 
and often ulcerated. 



passages of fre- 
blood-streaked 



The 
quent 

stools are accompanied 
by tenesmus. In the 
amoebic or tropical form, 
the diagnosis is made by 
an examination of the 
stools. 

Diarrhoea with blood 
and mucus in the stools, 
moderate fever, pain 
along the colon, and 
wasting of the body. 



Constipation from nar- 
rowing of the colon, and 
motor, sensory and vas- 
cular disturbances from 
falling down of the stom- 
ach and intestines. 



Severe spasmodic pain 
localized around the um- 
bilicus, relieved by pres- 
sure and the discharge 
of wind. Unattended by 
fever as a rule. 



The diagnosis is often 
difficult, and the case 
may furnish no symp- 
toms. The following 
symptoms are of note : 
diarrhoea, pain, and blood 
and pus in the stools. 



DISEASES OF INTESTINES AND PERITONEUM. 237 



DISEASES OF INTESTINES AND PERITONEUM— Continued. 



Etiology. 



Ttothology. 



Symptoms. 



12. INTESTINAL OBSTRUCTION. (Ileus.) 



Acute obstruction may be 
caused by : 1. Congenital 
occlusion. 2. Strangula- 
tion. 3. Twists (volvuhis). 
4. Intussusception. 

Chronic obstruction : 1. 
Faecal accumulations. 
2. Strictures. 3, Foreign 
bodies (gall-stones). "4. 
Tumors. 



13. PERITONITIS. 

Primary peritonitis 
may arise from exposure 
to cold or traumatism. 
It may be secondary from 
extension of inflamma- 
tion from neighboring 
organs. Chronic perito- 
nitis may be caused by 
tuberculosis, s} 7 philis, 
cancer, etc. 



Strangulation is the 
most frequent cause of 
acute obstructions, and 
the site is usually in the 
small intestines. Twists 
are associated with a 
very long mesentery. 
The most usual site of 
intussusception is at the 
ileo-caecal valve, as it 
descends into the colon. 



According to the char- 
acter of the exudation, 
the inflammation may be : 
1, fibrinous ; 2, sero- 
fibrinous ; 3, purulent ; 
4, putrid ; 5, hemor- 
rhagic. 



Symptoms of acute ob- 
struction : constipation, 
pain in the abdomen 
and vomiting. The de- 
gree of abdominal dis- 
tension depends on the 
site of obstruction. 

('I ironic obstruction : 
same as foregoing, al- 
though the development 
of symptoms is slow. 



Moderate fever, ab- 
dominal tenderness, ab- 
dominal distension, vom- 
iting, pinched features 
and constipation. 



14. PSOROSPERMOSIS. 



Common in the inver- 
tebrates and rare in the 
higher mammals. The 
parasites are called p.so- 
rosperms, and they pro- 
duce in man a disease 
similar to that occurring 
in rabbits. 



In internal psorosper- 
miasis, nodules resem- 
bling tubercles and con- 
taining psorosperms are 
found upon the perito- 
neum, omentum, liver 
and other viscera. 



15. TYPHLITIS STERCORAEIS. 



Caused by the lodg- 
ment of the faeces and 
occurs especially in 
young pei sons who have 
been constipated or suf- 
fered some error in diet. 



An inflammation of s the 
caecum. Many cases of 
typhlitis are probably 
due to disease of the ap- 
pendix. 



Fever of an intermit- 
tent type, diarrhoea, ten- 
derness of the affected 
organs, _ and usually 
death. In cutaneous pm- 
rospermiasis, there are 
papillomatus growths 
containing psorosperms. 



Pain in the right iliac 
fossa. A sausage~-shaped 
doughy tumor "is present 
in this fossa. The fever 
is moderate. Prognosis 
is favorable. 



S38 MANUAL OP CLINICAL DIAGNOSIS. 



ANALECTIC REVIEW OF GASTRIC DIGES- 
TION AND GASTRIC NEUROSES. 

THE PROCESS OF DIGESTION. 

1. The first period of digestion in the stomach is the 
amylolytic, and consists in the conversion of starch into 
dextrine (achroo- and erythro-dextrine). The digestion is 
effected in the stomach by the swallowed saliva. 

2. Grape sugar, which is a final product of starch diges- 
tion, is converted into lactic acid by the action of micro- 
organisms that excite fermentation. 

3. The amylolytic period of digestion lasts, on an aver- 
age, three-quarters of an hour. 

4. Muriatic acid and pepsin are secreted immediately 
after the ingestion of food. 

5. When muriatic acid is first secreted it is in combina- 
tion, and the free acid is not present until three-quarters 
of an hour after the ingestion of food. 

6. Free muriatic acid inhibits amylolytic digestion, as 
the digestion of starch cannot proceed in an acid medium. 

7. Lactic acid disappears from the stomach one hour 
after the ingestion of food, or at a time when free muriatic 
acid is present. 

8. Simultaneous with the free hydrochloric acid, the 
milk curdling ferment {rennet ferment), which coagulates 
the casein of milk, and pepsin, are secreted. 

9. Pepsin and rennet ferment are not secreted as such, 
but are formed by their ferments, propepsin and rennet 
zymogen into pepsin and rennet ferment, respectively, un- 
der the influence of muriatic acid. 

10. The second or muriatic period of digestion consists 
in a peptonizing action of the gastric secretion upon the 
albuminous bodies. 

11. The free muriatic acid is antiseptic, destroying all 
microorganisms concerned in fermentation and putrefac- 
tion. 

12. During the period of digestion, some of the digested 
food is absorbed, while the remaining portion slowly passes 
into the duodenum. 



EXAMINATION OF GASTRIC DIGESTION. 230 

13. About six hours after a mixed meal, the stomach 
should be practically empty. 

14. In the intervals of digestion, the stomach contains 
only a small amount of clear fluid of neutral reaction. 

EXAMINATION OF GASTRIC DIGESTION. 

1. To determine the duration and other facts concern- 
ing digestion, the patient takes the experimental meal of 
Leube. 

2. Leube 9 s experimental meal consists of a plate of water- 
gruel, an ordinary piece of beef-steak, and white bread. 

3. Seven hours after the meal of Leube, if digestion is 
normal, the stomach should only contain a few remnants 
of food. 

4. After removal of the gastric contents, examinations 
must be made for the following: free muriatic acid, lactic 
acid, butyric and acetic acids, determination of the total 
acidity, determination of the digestive potver of the gastric 
juice, its coagulating effect upon milk, the transformation 
of starch, the presence of peptone and propeptoiie, the ab- 
sorptive and motive power of the stomach. 

5. The most certain test for hydrochloric acid is the 
pliloroghicin-vanillin test. It consists of phloroglucin two 
parts, vanillin one part, to thirty parts of absolute alcohol. 
One or two drops of this solution heated on a porcelain 
plate with the gastric contents (filtered), will, if free hydro- 
chloric acid is present, give a red color, the intensity 
depending on the percentage of the acid. It is distinct 
to 0.05 per thousand. 

6. The phloroglucin-vanillin test, or Gihnzberg's reaction, 
is only interfered with if sulphuretted hydrogen is present. 

7. Lactic acid is detected by the solution of Uffelman (to 
about three ounces of a two per cent, solution of carbolic 
acid, add one or two drops of chloride of iron solution). 
This steel-blue mixture becomes yellow or yellowish-green 
if lactic acid is present. It becomes like water if only HCL 
is present. The test may be counterfeited in the presence 
of phosphates, mineral acids, alcohol and grape sugar. 
These errors may be removed if the gastric secretion is 
shaken with ether. After evaporating the ether, dissolve 
the ether residue in water and apply test. 



240 MANUAL OF CLINICAL DIAGNOSIS. 

8. Butyric and acetic acids are recognized by their odor. 
They convert Vffelmarfs solution into a yellowish-red color. 

9. The total acidity of the gastric contents is determined 
by neutralizing it with a one-tenth normal solution of 
soda. 1 c.c. of the soda solution neutralizes 0.00365 of 
hydrochloric acid. 

10. The digestive power of the gastric juice is determined 
!)Y the digestion of a piece of the white of a hard-boiled 
egg or a bit of washed fibrin. See page 113. 

11. The coagulating effect of the gastric juice due to the 
rennet ferment is demonstrated as follows : add three to 
five drops of the filtered gastric juice to 10 c.c. of milk, 
when curdling will occur, in about fifteen minutes, at 37° 
to 40° C. 

12. The transformation of starch is tested by adding a 
drop of LugoVs solution (iodine one part, iodide of potash 
two parts, aq. dest. two hundred parts) to the filtered gas- 
tric juice. If starch is present the solution becomes blue, 
if erythrodextrin, purple. A mixture of starch and dex- 
trin with the first few drops of the solution becomes color- 
less, but upon adding more of the solution, it becomes red 
and then blue. 

13. The test for peptone is the biuret reaction. See 
page 112. 

14. Testing the absorptive and motive power of the stom- 
ach is described on page 113. 

ANOMALIES OF GASTRIC DIGESTION. 

1. Anacidity or inacidity denotes a condition in which 
free hydrochloric acid is absent. It occurs in destruction, 
atrophy and degeneration of the mucous membrane of the 
stomach, in gastric cancer with dilatation, in severe anae- 
mia, in febrile conditions, and in certain cases of nervous 
dyspepsia. 

2. Anacidity interferes with the digestion of albumen 
and the absence of hydrochloric acid favors putrefaction 
and fermentation. 

3. Hyperacidity or superacidity is a condition in which 
the free hydrochloric acid is present earlier than nsual and is 
in excess. It occurs in certain nervous dyspepsias {pyrosis 
hydrochlorica), and in acute and chronic gastric catarrh. t 



241 GASTRIC NEUROSES. 

4. Hyperacidity interferes with the digestion of starch. 
Albuminous bodies are usually rapidly peptonized. 

5. Chronic hypersecretion signifies a continuous secretion 
of gastric juice even though the stomach is empty. The 
fluid present resembles gastric juice with a high degree of 
acidity. 

GASTRIC NEUROSES. 

1. When a patient has a ravenous appetite which he 
finds difficult to satiate, the condition is called bulimia or 
polyphagia. It may occur alone or as a symptom of many 
nervous affections, neurasthenia, hysteria, psychoses, etc. 
It is likewise a prominent symptom in diabetes. 

2. Pica is a condition of perverted apj)etite often symp- 
tomatic of hysteria, in which the patient craves for ink, 
chalk and other substances. 

3. Anorexia is a lack of appetite or repugnance for food. 
It accompanies many dyspeptic and mental disturbances. 

4. Gastralgia or Gastrodynia is a neuralgic affection of 
the stomach dependent on irritation of the sensory nerves. 
It may be symptomatic of tabes (gastric crises), hysteria, 
neurasthenia, primary anaemia and various mental diseases. 

5. An increased secretion of hydrochloric acid {hyper- 
acidity) may exist as a primary neurosis of the stomach. 

6. Nervous belching occurs in hysteria and neurasthenia. 

7. Pneumatosis is a condition in which the stomach is 
inflated with air often conducing to typical asthmatic 
attacks (asthma dyspepticiim). 

8. Nervous vomiting is frequent in hysteria. It is not 
attended by severe nausea or retching. 

9. Peristaltic unrest of the stomach is a condition usually 
dependent on gastrectasis, in which the peristalsis of the 
stomach is so marked, that the movements may be ob- 
served through the relaxed abdominal parietes. The move- 
ments may be attended by loud rumbling sounds. 

10. Nervous anacidity is often encountered as a pure 
neurosis in hysteria and neurasthenia. 

11. Incontinence of the pylorus and cardia are condi- 
tions likened to paralysis. Paresis of the latter allows of 
the regurgitation of air and food, while paresis of the 
former allows the undigested food to pass at once into the 
intestines. 



242 MANUAL OF CLINICAL DIAGNOSIS. 

12. Incontinentia pylori may be recognized by distend- 
ing the stomach with air or gas (tartaric acid and bicar- 
bonate of soda). It will be noted that the stomach becomes 
incompletely distended, and that the air or gas passes at 
once into the intestines. 

13. Rumination or merycismus is a neurosis in which 
food, after it is ingested, returns to the mouth to be chewed 
and swallowed a second time. 

14. Atony of the stomach may be partial or complete. It 
is suppressed peristalsis of the stomach. 

RELATION OF DISEASES OF THE STOMACH TO 
OTHER DISEASES. 

A?icemia. — Absorption and peristalsis of the stomach are 
disturbed, leading to a complex variety of digestive dis- 
turbances. 

Cardiac Diseases. — As a result of venous congestion, 
catarrh of the stomach occurs. 

Diabetes. — Dyspeptic disturbances frequently serve, as an 
index to this disease. Hydrochloric acid, w r hen temporarily 
absent, maybe merely an expression of a neurosis; if absent 
permanently, the cause is atrophy of the mucous mem- 
brane, the result of interstitial inflammation. 

Gout. — There may be a specific gouty disorder of the 
stomach, the result of the uric acid diathesis, or the stom- 
ach may participate in the symptoms of this affection. 

Hepatic Diseases. — Many affections of the liver may be 
disguised as a chronic gastric catarrh. There is an inti- 
mate relationship existing between the functions of both 
organs. 

Malaria. — Aside from dyspeptic disturbances as mani- 
festations of this disease, there are typical neuroses with 
characteristic periodicity, which yield to quinine. 

Nervous Diseases. — In tabes dorsalis, paroxysms of gas- 
tralgia and gastric crises occur not only in the late, but in 
the early stages of the disease. Gastric crises are severe 
paroxysms of pain, confined to the epigastrium, accompa- 
nied by painful and uninterrupted vomiting, nausea and 
vertigo. A characteristic feature of the crises is this, that 
almost immediately after the pains cease, the patients de- 
mand food, which they digest perfectly. 






THE EMPLO YMENT OF DR UQS IN DIA GNOSIS. 243 

Renal Diseases. — Disturbances of digestion and vomiting 
occur as a result of the excretion of excrementitious prod- 
ucts by the stomach, symptoms in reality of ursemia. 
Mobility of the kidney may cause gastrectasis by compres- 
sion of the duodenum. 

Tuberculosis. — Many cases of phthisis begin with dys- 
peptic disturbances ; in fact, Hutchinson maintains that 
dyspeptic symptoms precede the onset of tubercular mani- 
festations in thirty-three per cent, of the cases. Fenwick 
found evidences, of gastric catarrh in seventy-three per 
cent, of his phthisical cases. 



THE EMPLOYMENT OF DRUGS IN 
DIAGNOSIS. 

Cocaine. — As a local anaesthetic, this drug subserves a 
useful purpose in diagnosis. Eecurring or persistent head- 
aches, as well as a large group of neuroses, are often de- 
pendent on some abnormity in refraction, or to an improper 
balance between the sets of muscles which regulate the 
ocular movements. A solution of cocaine, sprayed on the 
ocular conjunctiva, paralyzes the accommodation, and will, 
in many instances, for the time being, ameliorate or cause 
to disappear the reflex symptoms dependent on the ocular 
defect. For examining the back ground of the eye, dila- 
tation of the pupil had better be secured by cocaine than 
by atropine, inasmuch as the latter paralyzes the accom- 
modation for too long a period. Any irregularity in the 
dilatation of the pupil may direct attention to an old iritis. 
Among the reflex nasal neuroses, the following may be 
cited: headache, vertigo, insomnia, neuralgic affections in 
typical situations (scapula, sternum, renal region), and dis- 
turbances in the visceral functions (asthma, palpitations, 
vomiting, etc.). If the nasal mucous membrane is anaes- 
thetized by cocaine, many of these neuroses, will disappear, 
thus furnishing an invaluable aid in diagnosis. Various 
reflex troubles may originate from urethral irritation, espe- 
cially from stricture. These reflex troubles may merely 
amount to pains in the perineum, abdomen, and in other 
remote parts, or they may constitute such affections as 
neurasthenia, epileptiform convulsions, etc. The urethral 



244 MANUAL OF CLINICAL DIAGNOSIS. 

instillation of a solution of cocaine may prove an aid in 
diagnosis. Similarly, reflex rectal, uterine, vaginal and 
laryngeal troubles may be determined. 

Nitrite of Amyl. — The physiological action of this 
remedy is to produce vascular dilatation. It is adminis- 
tered by inhalation. The pains of angina pectoris are fre- 
quently relieved by the inhalation of this substance, and it 
may serve as a means of differentiation from pseudo-a?igina. 
Headaches of anaemic origin are relieved, whereas, if the 
headache is of hyperaemic origin, it is intensified. Spastic 
migraine is relieved, while paralytic migraine is intensified. 
Neuralgias of anaemic origin are likewise benefited. I 
have used inhalations of amyl nitrite in differentiating the 
rales of asthma from those of the accompanying bronchitis ; 
the former disappear, while the latter persist. In many 
pulmonary neuroses of spasmodic character, nitrite of 
amyl inhalations are of signal advantage in aiding the 
results of auscultation. 

Iodide of Potash. — This remedy, like mercury, is 
almost diagnostic when benefit is secured, from its adminis- 
tration in neuralgias, ulcerations, paralyses, etc., of syphi- 
litic origin. It must be given alone, and in large doses, 
until its physiological action is secured. It is also used in 
the diagnosis of suspected pulmonary tuberculosis when in 
apical lung affections, dullness or modified respiration is 
present without rales. The latter may be artificially pro- 
duced by its administration. When the cough is dry with- 
out sputa, the latter may be produced by giving iodide of 
potash. To intensify the auscultatory phenomena of an 
old plenritis, iodide of potash, by increasing the secretions, 
may be of some value. It is also used for determining the 
absorptive power of the stomach (see page 113). The value 
of potassium iodide in the removal by resorption of hyda- 
tid cysts is determined by its administration in a given 
case. If aspiration of the sac shows the presence of iodine, 
then the potash treatment will be of value, otherwise, the 
results will prove negative. 

Iron. — The ferruginous preparations are of diagnostic 
value in determining the ancemic origin of neuralgias, head- 
aches, cardiac murmurs, etc. They should disappear or 
become ameliorated after their persistent use. In chlorosis, 



EMPL TMEWT OF DRUGS IX DIA GNOSIS. 2 f 5 

iron is a specific. Iron intensifies the symptoms of any 
affection due to plethora. It is always better to look upon 
anaemia, not as a substantive, but as a symptomatic affec- 
tion. I have shown elswhere that pulmonary atelectasis 
(page 50) is a frequent factor in the etiology of anaemia, 
and furthermore, that by persistent, daily, methodical lung 
gymnastics, many intractable forms of anaemia may be 
cured. 

Digitalis. — This drug, by slowing the action of the 
heart, is of value in irregular action of that organ, to de- 
termine the time of a murmur, should this be present. At 
the same time, by increasing the force of the heart's action, 
it will render cardiac murmurs more distinct, inasmuch as 
the intensity of a murmur is dependent on the activity of 
the heart. Fluid in the pericardium may be an exudation 
or transudation. Digitalis, by increasing diuresis, will 
often cause the resorption of the latter, leaving the former 
unaffected. Kesorption is noted by a diminution in the 
area of precordial dullness. In tachycardia, resulting from 
vagus paralysis, the heart does not respond to digitalis. 

Quinine. — In the typical forms of malaria, the diagno- 
sis is always easy ; but there are types of the disease in 
which the febrile manifestations are irregular. In the lat- 
ter cases, the therapeutic test of quinine is unquestioned, 
for the symptoms of malaria, however unusual, always 
yield to quinine. Any intermittent fever which does not 
respond to quinine is not malarial. In applying this 
therapeutic test, we must be lavish with our drug, always 
carrying it to its physiological effects, and maintaining 
them for several days. 

Colchicum. — This is a specific palliative in acute gout. 
There are cases of irregular gout dependent on a so-called 
gouty diathesis, with a train of manifestations implicating 
nearly every organ of the body. Among the symptoms, 
headache and neuralgia are frequent. It is in the irregu- 
lar cases of gout, that the colchicum test should be applied, 
coupled with the other routine methods of treatment. 

Ergot. — The action of this drug is to produce arterial 
anaemia, and its use is suggested in the differential diag- 
nosis of anaemic and congestive affections. The latter w T ill 
be ameliorated. 



246 MANUAL OF CLINICAL DIAGNOSIS. 

Salicylic Acid. — This preparation is almost a specific 
in rheumatic affections, especially in the acute cases. In 
atypical manifestations of presumable rheumatic origin, 
the salicylates should always be given as a therapeutic test. 

Salol. — This agent is used for determining the motor 
activity of the stomach. It is a compound of phenol and 
salicylic acid, and it is only split up in an alkaline medium. 
After taking fifteen grains of salol in a capsule, salicyluric 
acid will be detected in the urine in from forty to seventy- 
five minutes ; which shows that the salol has passed out of 
the stomach. The acid may be easily detected by placing 
a drop of urine on filter paper ; if to the latter a drop of a 
ten per cent, ferric chloride solution is added, a violet 
color appears. In atony of the stomach and gastric dilata- 
tion, the salicyluric acid may not be detected in the urine 
for many hours. There are many cases of diarrhoea due to 
bacteritic intestinal infection. A diarrhoea of this kind 
responds favorably to salol or any other intestinal anti- 
septic. 

Opium. — This drug will relieve dyspnoea produced by 
many painful thoracic affections. 

Anaesthetics. — They are employed in the detection of 
simulation of various kinds. It- may only be necessary to 
carry the action of the anaesthetic up to the stage of excite- 
ment. 

Hysteria is an affection which may simulate almost any 
disease, and the detection of the malady is often possible 
only after narcosis. Hysterical contractures and joint 
affections are examples. 

A phantom tumor is of hysterical origin. It is produced 
by relaxation of the recti muscles and spasmodic contrac- 
tion of the diaphragm in conjunction with gaseous infla- 
tion of the intestines, and an arching forward of the ver- 
tebral column. This tumor always disappears under full 
anaesthesia, A thorough palpation of the abdomen is only 
possible, in many cases, after complete relaxation of the 
abdominal parietes under an anaesthetic. 

Blisters. — They are of value in diagnosis when it is 
necessary to secure the blood serum for examination, as in 
the application of Garrod's test (page 100). The serum of 



BECENT METHODS OF DIAGNOSIS. 247 

blisters produced over suspected leprous patches may con- 
tain the bacilli of leprosy. 

Anthelmintics. — There are many nervous phenom- 
ena, such as epilepsy, convulsions and chorea, which may 
be caused by intestinal parasites. In all cases of doubt 
regarding the etiology of a neurosis, intestinal parasites 
should be excluded by the administration of an anthel- 
mintic. 

Parasiticides. — There are many skin affections of a 
parasitic origin, the nature of which can always be satis- 
factorily determined by the application of parasiticides. 

Jaborandi. — This powerful diaphoretic is usually em- 
ployed in the form of its alkaloid, pilocarpine. It is not 
infrequent, especially in children, that a pleuritic effusion 
may yield the same physical signs as a pneumonia, in which 
case a differentiation may be necessary without having re- 
course to the exploratory needle. If the upper line of dull- 
ness is marked and then an hypodermic injection of pilo- 
carpine is given, the line of dullness on percussion w T ill be 
lower after than before the injection. Pulmonary oedema 
may be differentiated from the first stage of pneumonia 
and capillary bronchitis in a similar manner, the rales of 
the former disease often disappear for a limited time, at 
least, after the injection. 

RECENT METHODS OF DIAGNOSIS. 

Intra-Thoracic Auscultation.— Dr. B. W. Eichard- 
son employs for this purpose an oesophageal tube with a large 
aperture at the end. An aperture in the tube is necessary, 
otherwise there will be poor conduction of sound. The 
free end of the tube is connected with a binaural stetho- 
scope. This method, according to the writer, is found 
applicable in diagnosing pulsating tumors (aneurisms) as 
they pulsate along the oesophagus and stomach. It is also 
of service in diagnosing diseases of the heart. Eecourse is 
not had to this method unless the conventional methods 
yield negative results, 

A New Method of Auscultatory Percussion. — 

This method, advocated by Dr. A. H. Smith, may be con- 



248 MANUAL OF CLINICAL DIAGNOSIS. 

ducted with the usual binaural stethoscope, to which is at- 
tached the small extremity intended for examining the 
heart, but this, instead of being applied to the chest, is held 
between the patient's teeth, and the lips are closed around it. 
During the percussion the nostrils are compressed with the 
fingers. By this method there is a confined column of air, 
reaching uninterruptedly from the patient's lung to the 
examiner's ear. I have employed this method of examina- 
tion and can recommend it, when it is desirable to intensify 
the sounds obtained by ordinary percussion. The pneu- 
matoscope described on page 46, embodies the principle of 
the method just described, but it is more complicated and 
yields poorer results. 

Determining the Lower Liver Border by Aus- 
cultation. — This method, described by C. Verstraelen, is 
based on the fact that the intensity of the heart tones is 
well preserved over the entire hepatic region; at the lower 
border of the liver, however, the tones are suddenly lost. 
In this way, the lower liver border is determined. The ab- 
dominal walls must be relaxed, otherwise they will conduct 
the heart tones. I consider this an imperfect method of ex- 
amination, especially if the heart tones are weak. The de- 
marcation of the lower liver border by percussion is very diffi- 
cult, if not often impossible, in the epigastric region, owing 
to the relative thickness of the abdominal parietes and the 
thinness of the liver border. My method of determining 
the lower liver border by linear percussion is as follows : 
the patient is placed in a position favoring the approxima- 
tion of the liver to the abdominal walls. This position is 
the knee-elbow one, or if this is impossible, by the erect 
posture, the body being inclined forward. The edge of a 
large coin is then deeply imbedded in the abdominal walls, 
and the free edge of the coin is percussed lightly until a 
dullness is obtained. If this dullness represents the liver 
border, then, in accordance with the fact that the liver 
undergoes respiratory dislocation, the line of dullness will 
be lower during inspiration and higher during the act of 
expiration. The essential principle embodied in my method 
is this, to verify the correctness of my percussion by dis- 
location of the organ during respiration. This method 
will be found applicable in the percussion of the anterior 
border of the spleen, remembering, however, the addi- 



RECEXT METHODS OF DIAGNOSIS. &48 

tional fact, that change of posture will also influence the 
position of this viscus. 

A New Diagnostic Sign of Stenosis of the 
(Esophagus.— According to Dr. Vanni, a sub-tympanitic 

sonorous sound is discovered by percussion on the left side 
of the vertebral column, the area affected occupying a rect- 
angular space with a longitudinal axis. This resonance is 
changed into dullness when the patient has drunk a large 
quantity of fluid. If the oesophageal sound is then intro- 
duced down to the point of the stricture, it brings out a 
muddy and fetid fluid. Besides these diagnostic signs, the 
following phenomenon is noted: on assuming a reclining 
position, the pulsations of the femoral artery dimmish in 
volume and strength when the patient drinks a quantity ot 
fluid exceeding thirteen ounces ; and if this liquid is slowly 
withdrawn, by means of the stomach pump, the beats of the 
femoral artery also slowly resume their normal amplitude. 

The Movements of the Diaphragm.— The move- 
ments of this muscle have, heretofore, been determined by 
percussion. According to Sutton, they may be noted in 
nearly every individual. They are recognized by undulatory 
movements, beginning on either side at the sixth inter- 
costal space, descending a number of intercostal spaces 
during deep inspiration, to rise again during expiration. 
The play of the diaphragm can also be observed in the 
back For the proper observance of these movements on 
the anterior surface of the chest, the patient should be in 
the recumbent position. 

New Methods of Diagnosis in Aneurism.— If 
the extremities are tied, or if the femoral and axillary arte- 
ries are compressed, the pressure symptoms of an aortic 
aneurism become intensified. This is also true regarding 
the signs obtained by auscultation. Tracheal tugging is a 
valuable sign, first described by Porter. To test this, the 
patient is placed in the erect position and directed to c.ose 
the mouth and elevate the chin to the fullest extent then 
the cricoid cartilage is grasped between the thumb and 
fino-er and gently pressed upwards, when, if dilatation or 
amurism exists, the pulsation of the aorta will be distinctly 
felt, transmitted through the trachea to the hand. Dr. 
Wm. Evart has recently studied the occurrence ot this 



250 MANUAL OF CLINICAL DIAGNOSIS. 

symptom in healthy individuals. He found that, in health, 
the symptom is only slightly, if at all present. Drummond 
directs attention to the occurrence of a systolic murmur 
which may be heard in the trachea, or at the patient's 
mouth, when opened. It is either the sound conveyed 
from the sac, or is produced by the air as it is driven out 
of the trachea during the pulsations of the aneurism. 

Osier describes another important symptom in large 
thoracic aneurisms, and chat is, obliteration of the pulse 
in the abdominal aorta and its branches. In these cases, 
the cac probably acts as a reservoir, annihilating the ven- 
tricular systole and converting the intermittent into a 
continuous stream. 

The Clinical Value of Vertebral Tenderness, — 

In neurasthenia, tenderness over the vertebra? is rarely ab- 
sent. In acute transverse myelitis, there is frequently a zone 
of hyperesthesia at the level of the lesion, which may be dis- 
covered by passing a test-tube containing hot water along 
the spine, when the sensation of warmth changes to one of 
actual pain. In round ulcer of the stomach, Boas claims that 
there is a painful dorsal point of great diagnostic value. It 
is found at the level of, and to the left of, the tenth to the 
twelfth dorsal vertebrae. The painful area lies usually 
directly against the vertebra. In no other disease of the 
stomach is such a painful area to be found with equal con- 
stancy. Another as yet undescribed painful area described 
by the same author, is found in cholelithiasis, in the back, 
at the region of the twelfth dorsal vertebra, and somewhat 
to the right side ; this is found at the time of the attack, 
and even weeks and months thereafter. In caries of the 
vertebrae, the spinal processes of the affected vertebrae are 
painful on pressure, and pain is experienced when the ver- 
tebral column is moved. The muscles in the implicated 
district are nearly always rigid. In intercostal neuralgia* 
percussion of the vertebrae corresponding to the affected 
nerves will always elicit pain, 

Ehrlich's Method of Examination of the 
Blood. — In staining blood specimens, the haemoglobin 
must first be fixed on the cover glasses, but, instead of re- 
sorting to the complicated, although thorough method, as 
described on page 99, the cover glasses may be dropped into 



RECENT METHODS OF DL 1 GNOSIS. 251 

a solution of absolute alcohol and ether of equal parts. In 
a half-hour the specimen is ready to stain. The most con- 
venient stain for every day use is the following solution : 

Saturated aqueous solution of orange — G 125 

Saturated solution (in 20 per cent alcohol) of acid fuchsin. \2~> 

Absolute alcohol 75 

Saturated aqueous solution of methyl green 125 

The methyl green must be added drop by drop while 
stirring or shaking the solution. The solution must stand, 
some weeks, and the fluid used should be taken with 
a pipette from the middle of the solution. The cover 
glasses are stained in this solution for from tw r o to five 
minutes, washed in water, dried, and mounted in oil and 
balsam. With this stain, the red corpuscles are stained an 
orange or buff color, the nuclei of the colorless corpuscles 
green, the eosinophilic granules a deep red ; the nuclei of 
the nucleated red corpuscles, when present, deep green, 
almost black. The diagnostic value of the eosinopMle 
leucocytes in leukaemia has lately been questioned. They 
have been found in gonorrheal ptiG, purulent ophthalmia, 
human pus, in nasal polypi, and finally in the sputum of 
patients suffering from asthma, phthisis and bronchitis. 

The Heematokrit. — This instrument is so constructed 
as to separate by centrifugal force the blood corpuscles from 
the containing serum, the former being of greater specific 
gravity. 

One turn of the large wheel of this instrument causes 
the brass frame at the top of an upright piece of steel to 
revolve one hundred and four times. The frame receives 
two glass tubes, which are to contain the blood, each meas- 
uring thirty-five millimetres in length, and held securely 
in position by a spring. The glass tubes have a capacity 
of about twenty-seven and a half cubic millimetres, are 
three and three-fourths millimetres thick, thirty-five milli- 
metres long, and have a calibre throughout measuring one 
millimetre in diameter. A scale on the outside divides it 
into fifty equal parts, in the same manner as the scale on 
an ordinary thermometer. 

To obtain the volume of corpuscles : the blood is mixed 
with an equal quantity of a fluid preventing coagulation, 
and is then rotated ; the red corpuscles form a column at 



252 MANUAL OF CLINICAL DIAGNOSIS. 

the periphery of the tube, and measure, let us say, twelve 
and a half. As the blood is diluted one-half, this result is 
multiplied by two, equal to twenty-five, and to convert this 
into percentage it is again multiplied by two, as the scale 
is divided into but fifty parts, which gives fifty per cent. 

After considerable experimentation, Dr. J. Daland has 
concluded that a two and a half per cent, solution of po- 
tassium bichromate is by far the most useful liquid to 
dilute the blood for counting red blood-corpuscles. The 
method of applying the haematokrit is extremely simple, 
and requires very little additional apparatus. 

The haematokrit gives more accurate results than the 
apparatus of Thoma-Zeiss (page 96), and requires less skill 
and time in its employment. 

The Centrifugal Machine.— This apparatus is de- 
signed for the purpose of separating the corpuscular elements 
of fluids by centrifugal force. The motion is produced by 
two cog-wheels, that put in action a large beveled friction- 
wheel of rubber, causing a vertical spindle to revolve rap- 
idly ; to the latter a horizontal arm is connected, equally 
divided from a common centre, and containing two glass 
tubes, into which the fluid for separation is placed. By 
means of this apparatus casts can be separated from the 
urine in a few minutes. By means of this apparatus, I 
have frequently discovered elements in the urine, which, by 
the ordinary method of sedimentation by gravity, would 
never have been discovered. The galvanic current has 
also been used for obtaining a sediment. The current ob- 
tained from two zinc-carbon elements is passed, by means 
of platinum electrodes, through urine or other fluids con- 
tained in a bottle-shaped flask, during five to ten minutes. 
A layer of froth due to disengaged gas appears at the sur- 
face, and beneath this a turbid layer. If the current is 
allowed to act longer, the sediment sinks to the bottom. 

Ptomaine Poisoning. — Ptomaines are poisonous com- 
pounds developed from bacterial decomposition of animal 
matters. They are frequently ingested with the following 
tainted foods : 

1. Shell-fish and fish, — This follows the eating of either 
raw or cooked mussels, stale oysters, salted sturgeon, etc. 



RFj EXT M ETEODB OF I < S2& 253 

The symptoms are those of acute poisoning, with symptoms 

of collapse. The poison of the mussel is mytilotoxin which 
exists in the liver of the mussel. 

2. Milk. — The substance which causes the poisonous 
symptoms is tyrotoxicon. 

3. Meat. — Sausage poisoning (botulism) is relatively fre- 
quent. The symptoms are those of gastro-intestinal irri- 
tation, accompanied by headache., prostration, thirst, ab- 
dominal pain, excessive sweating and collapse. 

Illumination of the Stomach.— Renvers recently 
demonstrated to the Berlin Medical Society an apparatus 
which consisted of a small Edison's lamp fixed to the end 
of a bougie and covered by a small glass case filled with 
water. 

The electric current is obtained from a battery of twenty 
cells. If the stomach is full of food, illumination is impos- 
sible, but if it is quite full of water when the lamp is 
passed into the stomach an illuminated area is seen, which 
corresponds exactly to the limits of the organ. The appa- 
ratus can only be used in the erect posture, when the 
greater curvature is usually seen a little below the level of 
the umbilicus. 

. Abnormal dilatation of the stomach can be readily de- 
tected, and a case of carcinoma of the organ has been 
diagnosed by the use of this apparatus, the diagnosis being 
confirmed by post mortem examination. The tumor ap- 
peared as a dark spot in the light field. 

Transillumination as a Means of Diagnosis. — 

Antral empyema has been diagnosed by illuminating the 
bones of the face by an incandescent lamp introduced into 
the patient's mouth. Darkness on one side of an illumi- 
nated face might be taken as a probable symptom of empy- 
ema. The thickness of the bone varies so greatly in different 
individuals that it cannot be considered a reliable test. 
The diagnosis of pus in the antrum is often made by the 
simple method of Frankel. The nose having been thor- 
oughly cleansed, and it having been ascertained by inspec- 
tion that the nostril corresponding to the suspected antrum 
is quite free from secretion, the patient is instructed to lie 
down across a chair, holding the head down with the 



254 MANUAL OF CLINICAL DIAGNOSIS. 

affected side uppermost. After remaining in this position 
for half a minute, he is told to sit up, when an examination 
is made. Pus in the middle meatus will be noted if the 
discharge comes from the antrum. If a small incandescent 
lamp be inserted in the auditory meatus, in a dark room, a 
healthy mastoid is immediately illuminated with a ruddy 
glow. If the mastoid cells be occupied by a purulent col- 
lection, the glow will be absent and the cells dark. Com- 
parison with the healthy side should always be made. 

The Virile Reflex. — Dr. Hughes has recently directed 
attention to this reflex, which is obtained as follows : the 
penis is taken and pulled with some little force upwards in 
the direction of the umbilicus ; the foreskin is then caught 
near the fraenum, and the corpus cavernosum grasped with 
the second and third fingers ; if the corpus cavernosum 
is now struck with the other hand, a jerk is elicited. 
When this reflex is not obtained, the patient is said to be 
addicted to masturbation, or there is some loss of sexual 
power. 



INDEX. 



Abdomen, prominence of, 118. 
" retraction of, 118. 
11 topography of, 107. 
Abscess, of Brain, 213. 

" of lung, sputum of, 68. 
" retropharyngeal, 105. 
" subphrenic, 42, 121. 
Absolute cardiac dullness, 73. 
Acarus folliculorum, 189. 

" scabiei, 189. 
Acephalocysts, 187. 
Acetone, tests for, 154. 
Achorion Schoenleinii, 190. 
Acid, carbonic, 147. 
" hippuric, 145. 
" hydrochloric, 111. 
" lactic, 112. 
" oxalic, 145. 
" sulphuric, 146. 
" uric, 144. 
Acne, 224. 

" mentagra, 224. 
" rosacea, 2:24. 
Actinomyces, in sputum, 67. 
Actinomycosis, 229. 
Acute ascending paralysis, 209. 
" delirium, 197, 214. 
" miliary tuberculosis, 19, 68. 
" myelitis, 209. 
Addison's disease, 6. 
iEgophony, 51. 
^sthesiometer, 168. 
Agraphia, 168. 
Air, complemental, 38. 
" reserve, 37. 
" residual, 38. 
11 tidal, 37. 



Albumen, in urine, 147. 

" amount of, by sp. gr., 120. 

" qualitative tests for, 148. 

" quantitative tests for, 149. 
Albuminuria, 147. 

" with oedema, 8. 

Albuminometer, 149. 
Alcoholism, 203. 
Alcoholic dementia, 203. 
Alkali, fixed in urine, 140. 

" volatile in urine, 140. 
Almen's test, 150. 
Amblyopia, 166. 
Amoeba coli, 184. 

Ammonio-magnesium phosphate, 146. 
Ampere, 174. 
Amphoric respiration, 48. 

" sound, 42. 
Amphoteric reaction, 140. 
Amyl Nitrite in diagnosis, 244. 
Amylolytic digestion, 111. 
Amyotrophic lateral sclerosis, 164, 

182, 211. 
Anaemia, 96, 101, 

" cerebral, 212. 

" haemoglobin in, 95. 

M murmurs of, 81. 

" progressive pernicious, 101. 

" secondary, 101. 
Anaesthesia, 169. 
Anaesthetics in diagnosis, 246. 
Analectic review of gastric digestion, 
238, et seq^ 

" " of neuroses, 238, 

et seq. 
Analgesia, 169. 
Anasarca, 8. 
Anchylostomum duodenale, 188. 



256 



INDEX. 



Aneurism, murmur of, 86. 

" new methods of diagnosis, 

249. 
" signs of, 87, 88. 
" thoracic, 87. 
Aneurysmatoscope, 87. 
Angio-neurotic oedema, 220. 
Angle of Louis, 29. 
Anidrosis, 7. 
Anode, 175. 

Anomalies of gastric digestion, 240. 
Anorexia, 241. 
Anosmia, 166. 
Anthelmintics, 247. 
Anthrax, 234. 

bacillus of, 229, 234. 
Aortic valves, auscultation of, 76. 
" " disease of, 81. 

" " pulse curve of, 93, 94. 

Apex beat, 69. 

" l< causes of, 70. 
" "in disease, 70. 
" " in health, 70. 
Aphasia, 168. 
Aphonia, 23. 
Apnoea, 35. 
Apoplexy, 197, 212. 

" diathesis of, 2. 
" causes of hemiplegia, 166. 
" meningeal, 208. 
Appendicitis, 235. 
Apyrexia, 12, 17. 
Araometer, 142. 

Argyll-Robertson symptom, 174. 
Argyria, 7. 

Arterial murmurs, 86. 
Arteries, atheroma of, 93. 
" examination of, 85. 
" murmurs of, 86. 
" percussion of, 87. 
" tones of, 87. 
Arterio sclerosis, 85. 
Ascaris lumbricoides, 187. 
Ascites, causes of, 121. 
" diagnosis of, 120. 
" signs of, 119. 
Asiatic cholera, 123. 



Aspergillus, 67, 191. 
Aspermia, 158. 
Aspirating Emphysema, 8. 
Astasia abasia, 216. 
Asthma, causes of, 21. 
" crystals of, 63. 
" diagnosis of, 54. 
" sputum of, 68. 
" in uraemia, 144. 
Ataxia, 168. 

" Friedrieh's, 210. 
" hereditary, 210. 
" locomotor, 210. 
Atelectasis, 50. 
Atelectatic crepitation, 50. 
Atheroma, 93. 
Athetosis, 172, 217. 
Atony of stomach, 242. 
Atrophy, degenerative, 179. 

u idiopathic muscular, 221. 
" progressive muscular, 211. 
Auscultation, of arteries, 85. 
" of the chest, 45. 

" in disease, 48. 

" in health, 46. 

" of heart, 76. 

" of intestines, 119. 

" intra-thoracic. 247. 

" lower border of liver 

by, 348. 
" of larynx, 25. 

" methods of, 45, 247. 

11 of stomach, 107. 

" of veins, 89. 

" of voice, 51. 

Auscultatory percussion, 39. 
Auto-laryngoscopy, 23. 
Axioms of murmurs, 80. 



Bacelli, 51. 
Bacilli, 192. 
Bacillus, anthrax, 229, 234. 

" " in blood, 99. 

" cholera, 229, 233. 

" " nostras. 233. 

" coli commune, 232. 



INDEX. 



257 



Bacillus, comma, 383. 

diphtherias, 229, 233. 
Leprte, 230. 
ik mallei, 230. 

in blood, 100. 
11 pneumoniae, 230. 
" smegma, 234. 
11 syphilis, 193, 231, 234. 
" tuberculosis, 23:2, 234. 
" " iu blood, 100. 

11 " in sputum, 65. 

" in stool, 124. 

" typhosus, 232. 
" " in blood, 100. 

Bacteria, 191. 

classification of, 192. 
" demonstration of, 192. 

" non-pathogenic, 192. 

11 pathogenic, 192. 

" staining of, 193. 

Bacteriological diagnosis, 229. 
Bacterium coli commune, 232. 
Balantidium coli, 185. 
Barbers' itch, 225. 
Barrel-shaped chest, 32. 
Basedow's disease, diagnosis of, 183. 
Bass voice, 23. 
Beijwid's method, 123. 
Belching, nervous, 241. 
Bell's mania, 197, 214. 
Bell sound, 49. 
Biedert's method, 66. 
Biermer, 43. 
Bile, secretion of, 6. 
" stasis of, 5. 
l .* in urine, 150. 
Biliary acids, test for, 151. 
Biliary coloring matter, 151. 
Biuret reaction, 143, 148. 
Bladder, diseases of, 137. 

11 examination of, 134. 
Blastomycetes, 190. 
Blepharospasm, 171. 
Blisters, 246. 

Blood, animal parasites in, 100. 
" bacillus mallei in, 100. 
" bacillus tuberculosis in, 100. 



Blood, bacillus typhosus in, LOO. 

" chemical changes iii, 100. 

" coagulation of, LOO. 

" color of, 95. 

" diseases of, 101. 

u examination of, (Ehrlich), 250. 

u microorganisms in, 99. 

" microscopical examination of, 
96. 

" plaques of, 98. 

" quantity of, 95. 

" reaction of, 95. 

" spectroscopical examination 
of, 96. 

" specific gravity of, 96. 

" staining specimens, 98, 99. 

" tests for, 95. 

" tests for, in urine, 150. 

" in urine, 141. 

" corpuscles, counting of, 96. 

" " in the faeces, 122. 

" " number of, 96. 

" " size of, 97. 

" " in sputum, 62. 

" " white, counting of, 

97. 
Bloody flux, 236. 
Bottger's test, 152. 
Bradycardia, 90. 
Brain, abscess of, 213. 

" blood supply of, 163. 

" centers of, 161. 

" convolutions of, 161. 

" diseases of, 211, et seq. 

" lesions of, 163. 

" murmurs of, 87. 

" topography of, 205. 

" tumors of, 213. 
Brassy cough, 60. 
Breast, chicken, 32. 

" cobblers, 32. 

" funnel, 32. 

" rickety, 32. 
Brick-dust sediment, 144. 
Bright' s disease, 4, 8, 135, 182. 
Broca's convolution, 168. 
Bronchial breathing, 46. 



258 



INDEX. 



Bronchial breathing, forms of, 48. 
" casts, 64. 
" fremitus, 36. 
Bronchiectasis, diagnosis of, 54. 

" sputum of, 68. 

Bronchitis, diagnosis of, 54. 

" sputum of, 68. 

Bronchophony, 51. 

" whispering, 51. 

Bronchostenosis, 54. 
Bronzed skin, 6. 
Brown Sequard's paralysis, 210. 
Bruit de diable, 89. 

" " potfele, 42. 
Bulbar paralysis, 211. 

" " diagnosis of, 182. 

" " lesion of, 164. 

Bulimia, 241. 

Bullous inflammation of skin, 224, 
Burdach, columns of, 163. 

C 
Cachexia, with oedema, 8. 
Caisson disease, 209. 
Calcium carbonate, in urine, 147. 
Calculi, analysis of, 138. 
" biliary, 139. 
" of bladder, 137. 
" faecal, 139. 
" salivary, 139. 
" urinary, 138. 
Capillary pulse, 85. 
Carbonic acid, in blood, 4. 
" " in urine, 147. 

" oxide poisoning, 95. 
Cardiac diseases, diagnosis of, 83. 
" dullness, forms of, 73. 
" " area of, 74, 

Cardiograph, 71. 
Casts, bronchial, 64. 
" in faeces, 124. 
" of kidney, 156. 
" of seminal tubes, 157. 
Catarrhal pneumonia, 55. 
Catalepsy, 172, 198. 
Celsius, 10. 
Centers of brain, 161. 



Centers of cord, 164. 
Centigrade, 10. 
Centrifugal machine, 252. 
Cephalalgia, 170. 
Cercomonas intestinalis, 184. 
Cerebellar disease, gait in, 3. 
Cerebellum, lesion of, 164. 
Cerebral anaemia, 212. 
" embolism, 213. 
" haemorrhage, 212, 
" hyperemia, 212. 
" paralysis, 213, 218, 219. 
" syphilis, 204. 
" thrombosis, 213. 
Cerebro-spinal sclerosis, gait in, 3. 

" " meningitis, 19. 

Charcot-Leyden crystals, 63. 
Cheloid, 226. 

Chest, auscultation of, 45. 
" examination of, 28. 
" inspection of, 31. 
" landmarks of, 29. 
" lines of, 28. 
" mensuration of, 37. 
" movements of, 32. 
" palpation of, 35. 
" percussion of, 38, 40. 
" regions of, 28 
Cheyne-Stokes' respiration, 35. 
Chicken breast, 32. 
Chicken-pox, 15. 
Chigoe, 190. 
Chlorosis, 101. 

u haemoglobin in, 95. 
Chlorate of potash poisoning, 96. 
Chlorides, test for, 146. 
" in urine, 145. 

Choked disc, 183. 
Cholaemia, 5, 100. 
Cholera, bacillus, 229. 

11 " culture of, 123. 

" infantum, 235. 
" morbus, 235. 
" nostras, 235. 
" " bacillus of, 233. 

" stools in, 124. 
Cholesterine crystals, in sputum, 64. 



INDEX. 



259 



Cholesterine, test for, 139. 
Chorea, 172, 20:2. 

u acute, 214. 

" chronic, 202. 

" Huntingdon's, 202. 

" insaniens, 202. 
Chromidrosis, 7. 
Chyluria, 158, 189. 
Clavus hystericus, 170. 
Claw hand, 167. 
Clayey stool, 6. 
Clonic spasms, 170. 
Cobbler's breast, 32. 
Cocaine in diagnosis, 243. 
Colchicum in diagnosis, 245. 
Coli commune bacillus, 232. 
Colic, intestinal, 236. 
Collapse, pulse in, 91. 

11 temperature in, 11. 
Colon, dilatation of, 236. 
Coma, 197. 

" diabetic, 154. 
Comma bacillus, 229. 
Complemental spaces, 45. 
Conceptions, imperative, 190, 200. 
Condenser, achromatic, 194. 
Confluent small-pox, 14. 
Conidia, 190. 

Consciousness, disturbances of, 197. 
Constipation, 235. 
Contracture, 171. 
Convulsions, 171. 

" infantile, 214. 

Convulsive tic, 171. 
Corona veneris, 20. 
Corpora amylacea, 64. 

" quadrigemina, lesions of, 163. 
Corrosive sublimate, 191. 
Costo articular line, 29, 131. 
Cough, 60. 

" kinds of, 60. 

" signs obtained by, 61. 
Coughing, signs obtained by, 61. 
Countenance, expression of, 3. 
Cracked-pot sound, 42. 
Cramp, writers', 222. 
Cranial nerves, paralysis of, 166. 



Creatinine, 145. 
Cremaster reflex, 173. 

Crepitant rales, 49. 

Cretinism, 201. 

Crisis, 13. 

Crises, physiological, 202. 

Croup, 26. 

" diphtheritic, 26. 

" false, 26. 

" primary, 26. 
Croupous pneumonia, 55, 67. 
Cms cerebri, lesion of, 163. 
Crystals of Charcot, 63. 
" " haematoidin, 63. 
" " haemin, 95. 
" " semen, 159. 
Curschmann, spirals of, 64. 
Curve of Ellis, 41. 
Cutaneous emphysema, 9. 
Cyanosis, 4. 
Cysticercus, 186. 
Cystin, 155. 
Cystitis, 137, 138. 

I> 

Decubitus, 2. 
Defervescence, 13. 
Degeneration, reaction of, 179, 180. 
Delirium, 197. 

" acute, 214. 

" tremens, 203. 
Delusion, 199. 
Dementia, 200. 

" alcoholic, 203. 

" organic, 204. 

" paralytic, 200, 214. 

" " symptoms of , 200. 

" senile, 200. 

u terminal, 200. 

Dermography, 39. 
Detrusor vesicas, 137. 
Dextrose, 152. 
Diabetes, eye in, 182. 

" coma of, 154. 

" urine in, 141, 142. 
Diagnosis, by transillumination, 253. 

" drugs used in, 243, et seq. 



260 



INDEX. 



Diagnosis, in aneurism (new method), 
249. 
" of insanity, 198. 

" nervous diseases, 208, et seq. 
" recent methods of, 247. 
Diaphragmatic pleuritis, 35. 
Diarrhoea, 236. 
Diathesis, 2. 

Diazo reaction, 154, 155. 
Dicrotic pulse, 93. 

" wave, 93. 
Digestion, fever of, 11. 

" process of, 238, 239. 

Digestive system, 103. 
Digitalis in diagnosis, 245. 
Dilatation of colon, 236. 
Diphtheria, 19. 

" bacillus of, 229. 

Diphthonia, 23. 

Diplococcus pneumoniae, 230, 233. 
Diplopia, 166. 
Dipsomania, 203. 
Discrete small-pox, 14. 
Disease, Duchenne's, 211. 

" fish skin, 226. 

" functional nervous, 214. 

" Marie's, 220. 

" Meniere's, 198. 

" Parkinson's, 214. 

" Raynaud's, 220. 

" Thomsen's, 221. 
Tourette's, 217. 
Diseases of brain, 211, et seq. 

" " intestines, 235, et seq. 

" " muscles, 221, et seq. 

" " peritoneum, 235, et seq. 

" " skin, 223, et seq. 

ft " spinal cord, 208, et seq. 

" vaso-motor, and trophic, 220, 
et seq. 
Distoma haematobium, 100, 158. 
Divers' paralysis, 209. 
Donne's test, 151. 
Dracunculus medinensis, 190. 
Dropsy, 8. 

Drug exanthemata, 228. 
Drugs in diagnosis, 243, et seq. 



Duchenne's disease, 211. 
Dullness, liver, 127. 
Dysentery, 236. 
Dyspepsia, nervous, 115. 
Dyspnoea, 35. 

blood in, 95. 
Dystrophia muscularis progress., 181. 
Dysuria, 137. 

E 

Earthy phosphates, 146. 
Echinococcus cyst, 186. 
Eclampsia, 214. 
Ecstasy, 198. 
Eczema, 223. 

Ehrlich, blood examination of, 250, 
251. 

" diazo reaction of, 154, 155. 

" examination of sputum, 65. 
Elastic fibres, 64. 
Electricity, diagnosis by, 175. 

" forms of, 174. 

Electro-motive force, 174. 
Elephantiasis, 226. 
Ellis, curve of, 41. 
Emphysema of skin, 9. 

" spontaneous, 9. 

Emp3 T ema, organisms found in, 233. 

" pulsans, 71. 

Endocardial murmurs, 79. 
Enteralgia, 236. 
Entero-colitis, 236. 
Enteroliths, 139. 
Enteroptosis, 236. 
Entozoa, in sputum, 64. 
Eosinophilous cells, 98. 
Epigastric pulsations, 72. 
Epilepsy, 214. 

" Jacksonian, 216. 
Epistaxis, 22. 
Epithelium, in faeces, 123. 

" in kidney, 155. 

" from lung alveoli, 63. 

" " mouth, 63. 

" in sputum, 62. 

Erb, paralysis of, 167. 
Ergot in diagnosis, 245. 



INDEX. 



201 



Eruption, 130. 
Erysipelas, IS. 
Erythema multiforme, 2:23. 

11 nodosum, 223. 
Erythematous inflammation of skin, 

223. 
Esbach's albuminometer, 149. 
Etiology of insanity, 204. 
Examination of gastric digestion, 239, 
^ 240. 
" of the mind, 197. 

Exanthemata, drug, 228, 
Exanthematous diseases, stages of, 13. 
Exophthalmic goitre, 220. 

" " diagnosis of, 131. 

" " eye in, 183. 

" " tremor of, 172. 

Extra-pericardial murmurs, 81. 
Exudation, 120. 

" pleuritic, 41. 



Facial hemiatrophy, 220. 
Facies, Hippocratica, 3. 
Faecal tumors, 118. 
Faeces, 121. 

" microscopical examination of, 
121. 

" macroscopical examination of, 
121. 
Fahrenheit, 10. 
Fastigium, 13. 
Faeces, 104. 
Favus, 190, 228. 
Febris, continua, 12. 

" hectica, 13. 

" intermittens, 12, 17. 

" recurrens, 12, 99. 

" remittens, 12. 

" stupida, 13. 

" versatilis, 13. 
Fehling's test, 152. 
Fenwick's method, 64. 
Fermentation test, 153. 
Fever, character of, 13. 

" of digestion, 11. 

" dynamic or sthenic, 13. 



Fever, lesions of, 11. 
" relapsing, 231. 

" stages of, 13. 

" symptoms of, 11. 

" thermic, 221. 
Fibres, elastic, 64. 
Fibrin in urine, 149. 
Filaria sanguinis hominis, 158, 184, 188, 
Fish skin disease, 220. 
Fleischl's hasmometer, 90. 
Flexibilitas cere a, 172. 
Floating kidney, 134. 
Flopping gait, 3. 
Floccitatis, 13. 
Flux, bloody, 236. 
Folie circulaire, 199. 
Foot clonus, 173. 
Forms of idiocy, 200. 
Fossa of Mohrenheim, 29. 
Franklinism, 174. 
Fremitus, bronchial, 36. 
" friction, 36. 

" pleural, 36. 

" vocal, 36. 

Friction sounds, pleural, 50. 
Friedlander's method, 67. 
Friedrich's ataxia, 210. 
Fuchsin, 193. 
Functional nervous diseases, 214, el seq. 

paralysis, 218, 219. 
Funnel breast, 32. 
Furrow of Harrison, 29. 

" " Gibson, 29. 

G 

Gabbet's method, 66. 
Gait, in nervous diseases, 2. 
Galacturia, 142. 

Gall bladder, examination of, 126, 
Gall stones, 139. 
Galvanic current, 175. 
Gangrene, symmetrical, 220. 
Garrod's method, 100. 
Gastralgia, 241. 
Gastrectasis, 241. 
Gastric cancer, 114. 
" catarrh, 114. 



262 



INDEX. 



Gastric digestion, 238, et seq. 

" " analectic review of, 

238, et seq. 

" " anomalies of, £40, 

241. 

" " examination of, 239, 

240. 

" juice, digesting capacity of, 13. 

" neuroses, 238, et seq. 
Gastro-duodenal catarrh, 5. 
Gastrodynia, 241. 
Gastroscope, 110. 
General paralysis of the insane, 200. 

" paresis, 214. 
Genito-urinary organs, 133. 
Gerhardt, 143. 
Giacomi, method of, 193. 
Girdle pain, 170. 
Glanders, 230. 

" diagnosis of, 234. 

Globus hystericus, 171. 
Glosso-labio-laryngeal paralysis, 211. 
Glottis, 22. 

" oedema of, 26. 
Gluteal reflex, 1?'3. 
Glycosuria, 152. 
Gmelin's test for bile, 150. 
Goitre, exophthalmic, 220. 
Goll, columns of, 
Gonococcus, 193, 230. 
Gonorrhoea, 230. 
Gouty diathesis, 2. 
Gower's apparatus, 95. 
Graefe's symptom, 183. 
Gram's method, 193. 
Grape sugar in urine, 152. 
Graphospasm, 222. 
Gravel, 138. 

Grave's disease, pulse of, 91. 
Gubler, line of, 163. 
Guinea worm, 190. 
Gums, 114. 
Giinzberg's test, 112. 

H 

Haematemesis, 22, 114, 116. 

" diagnosis of> 116. 



[ Haematin, 95. 

Haematoblasts, 98. 
| Hematogenic icterus, 6. 
I Haematoidiu crystals, 63. 
I Haematokrit, 251. 
Haematorrhaehis, 208, 
Haematozoa, 100. 
Hematuria, 141, 189. 
Haemic murmurs, 80. 
Haemin, 95. 
Haemoglobin, 75. 

" reduced, 96. 

Haemoglobinaemia, 96. 
Haemoglobinometer, 95. 
Haemoglobinuria, 141. 
Haemometer, 95. 
Haemoptysis, 22, 62, 116. 

" diagnosis of, 116. 

Haemorrhagic infarction, (5S. 
Haemorrhagic-pachy-meningitis, 211. 
Half-moon-shaped space, 41. 
Hallucination, 198. 
Headache, 170. 
Heart, auscultation of, 76. 

" changes in location of, 75. 

" diseases of, 83. 

". enlargement of, 70. 

" examination of, 69. 

u hypertrophy of, 83. 

" murmurs of, 81. 

" palpitation of, 82. 

" percussion of, 73. 

u pulsation of, 71. 

" resistance of, 74. 

" rhythm of, 77. 

" size of, 75. 

" sounds of, 76o 

" thrills of, 72. 

" tones of, 77, 78, 79. 

" weight of, 75. 
Heller's test, 148, 150. 
Hemialbumose, 149. 
Hemianaesthesia, 169. 
Hemianopsia, 166. 
Hemiathetosis, 172. 
Hemiatrophy, facial, 220« 
Hemichorea, 172. 



INDEX. 



263 



Hemicrania, 214. 
Hemidrosis, 7. 
Hemiplegia, cause of, 165. 
gail in, 2. 
Lesion of, 165. 
Hepatogenic icterus, 5. 
Hereditary ataxia, 210. 
Herpes of lips, 12. 
Herpes Zoster, 223. 
Hiccough, 171. 
Hippocrates, 3. 
Hippuric acid, 145. 
Hives, 223. 
Hoarse voice, 23. 
Hodgkin's disease, 102. 
Hook worm, 18S. 
Hopping gait, 3, 52. 
HulmerfVkrs mixture, 150. 
Huntingdon's chorea, 202. 
Hydatid cyst, 186. 

" " fremitus of, 134. 

Hydremia, 8. 
Hydrocephalus, 214. 
Hydrochloric acid, tests for, 111, 112. 
Hydropericardium, 74. 
Hydrops, 8. 

" vesicae f elite, 126. 
Hydrothorax, 41. 
Hypaesthesia, 169. 
Hyperesthesia, 169. 
Hyperidrosis, 7. 
Hyperpyrexia, 12. 
Hypertrophy of left ventricle, 83. 
" of right ventricle, 83. 

" pseudo muscular, 222. 

Hypochondria, 201. 
Hysteria, 202, 215. 

" diagnosis b}^ anaesthetics, 
246. 

" hemiplegia of, 3. 
Hysterical stigmata, 202. 
Hystero-epilepsy, 202. 



Ichthyosis, 226. 
Icterus, 4. 



lei ens, haematogenic, 6. 
u hep itogenic, 5. 
11 neonatorum, '*>. 
" symptoms of, 5. 
" \ : rid is, 5. 
Idiocy, forms of, 200. 
Idiopathic muscular atrophy, 221. 
Ileus, 237. 

Illumination of stomach, 258. 
illusion, 1*99. 
Imbecility, 201. 

Imperative conceptions, 199, 200, 
Impetigo, 224. 

" contagiosa, 224. 

Impulse, morbid, 199. 
Incontinence of cardia, 241. 

" pylorus, 108, 241,242. 
Incubation, 13. 
Indican, 141. 
Indicanuria, 141. 
Infantile convulsions, 214. 

" paralysis, 181. 
Infarction, hemorrhagic, 68. 
Inflammation with oedema, 8. 
Inflammations of skin, 223, et seq. 
Infusoria, 184. 
Inosite, 154. 

Insane, general paralysis of, 200. 
Insanities, toxic, 204. 
Insanity, diagnosis of, 198. 
" etiology of, 204. 
" moral, 199. 
" periodical, 199. 
" prognosis of, 204. 
Inspiration, muscles of, 33. 
Insular sclerosis, 214. 
Intercostal neuralgia, 35. 
Intermittent aphonia, 23. 
Internal capsule, lesion of, 163. 
Intestinal colic, 236. 

M obstruction, 237. 

" ulcers, 236. 

Intestines, auscultation of, 119. 
" diseases of, 235, et seq. 

" inspection of, 117. 
" palpation of, 118. 
" percussion of, 118. 



264 



INDEX. 



Intestines, tumors of, 118. 
Intra-thoracic auscultation, 247. 
Iodide of potash in diagnosis, 244. 
Iron in diagnosis, 244. 
Ischuria, 137. 
Itch, 227. 
kt barbers', 225. 



Jaborandi, 247. 
Jacksonian epilepsy, 216. 
Jactitation, 2. 
Johnson's test, 153. 

K 

Kathode, 175. 

Kidnej^s, anatomy of, 133. 

14 diseases of, 135, 136. 

" percussion of, 134. 

" physiology of, 133. 

" tumors of, 134. 
Kleptomania, 200. 
Koch's lymph, 56. 
Kyphosis, 21. 



Labyrinthine vertigo, 198. 
Lactic acid, tests for, 113. 
Landry's paralysis, 209. 
Laiyngismus stridulus, 171. 
Laryngitis, 25. 
Laryngoscopy, 22. 
Larynx, anatomy of, 22. 

" diseases of, 25. 

" palpation of, 25. 

" percussion of, 25. 

" syphilis of, 26. 

" tuberculosis of, 26. 
Lateral sclerosis, 209. 

" " amyotrophic, 211. 

" " gait in, 3. 

" " lesion of, 164. 

Lead poisoning, 168, 183. 
Legal' s test, 154. 
Lepra bacillus, 230. 
Leprosy, 230. 
Leptomeningitis, 208, 212. 



Leptothrix buccalis, 65. 
Leucaemia, 95, 98. 

" eye in, 182. 
Leucin, 155. 
Leucocytes, 98. 
Leucocytosis, 98, 101. 
Leucoderma, 227. 
Lichen ruber, 226. 

" scrofulosis, 226. 
Lieben's test, 154. 
Lientery, 124. 
Line of Gubler, 163. 
Lines of thorax, 28, 29. 
Lipaemia, 100. 
Lips, 103. 
Lipuria, 142. 
Liver, anatomy of, 125. 
" auscultation of, 129. 
" borders of, 127. 
" diseases of, 128. 
" inspection of, 125. 
" lower border by auscultation, 

248. 
" palpation of, 126. 
" percussion of, 126. 
" venous pulse of, 189. 
Localization, spinal, 206, 207. 
Lockjaw, 171. 
Locomotor ataxia, 210. 
Lordosis, 31. 
Louis, angle of, 29. 
Lungs, auscultation of, 46, et seq. 
" borders of, 43, 44. 
" capacity of, 37. 
" dislocation of, 44. 
" dullness of, 40. 
" percussion of, 43. 
" physical signs of, 53. 
" sputum in disease of, 67, etseq. 
" table of diseases, 54, et seq. 
Lymph, Koch's, 56. 
Lysis, 13. 

M 

Machine, centrifugal, 252. 
Macro cytes, 97, 
Macroglossia, 201. 



INDEX. 



Magnesium phosphate, 146. 
Malaria, 17, 280. 
Malignant oedema, 235. 
pustule; 284. 
Mania, L99. 

" a p6tu, 203. 

" Bell's, 197,214. 

" puerperal, 203. 
MarechaTs test, 150. 
Margaric acid, 63. 
Marie's disease, 220. 
Measles, 13. 
Mechanical hydrops, 8. 
Medical cases, examination of, 1. 

" ophthalmology, 182. 
Medulla oblongata, lesion of, 164. 
Melanaemia, 99. 
Melancholia, 199, 201. 
Melasicterus, 5. 
Meniere's disease, 198. 
Meningeal apoplexy, 208. 
Meningitis, 19. 

" tuberculous, 212. 

Menopause, 203. 
Mensuration, 37. 
Merycismus, 242. 
Metamorphosing respiration, 48 
Meteorismus, 118. 
Method of Beijwid, 123. 

" of Schottelius, 123. 
Methods of diagnosis, recent, 247. 
Micrococci, 192. 
Microsporon furfur, 190. 
Micro organisms, figure of, 194. 
" " in sputum, 65. 

11 " staining of, 192. 

Microcytes, 97. 
Migraine, 214. 
Miliaria, 223. 
Milliampere, 175. 
Mind, examination of, 197. 
Mitral lesions, pulse curve of, 94. 
Mitral regurgitation, 84. 

pulse of, 92. 
" stenosis, 84. 
Mitral valves, diseases of, 84. 
Molisch's test, 153. 



Monomania, L99. 
Monoplegia, L65. 
Moore's test, L52. 
Moral Insanity, 199. 
Morbid inpulse, 199. 
Morbilli, L3. 
Morbus caeruleus, 5; 

Weilii, 6. 
Motor points, 175. 

" " illustrations of, 170, 

177, 178. 
Mouth, odor from, 103. 
Mucin, tests for, 150. 
Mucus in fasces, 122. 
Muguet, 104. 
Mulder's test, 153. 
Multiple neuritis, 208. 

" sclerosis, 181. 
Murexide test, 138, 144. 
Murmurs, anaemic, 81. 

" aneurysmal, 86. 

" arterial, 86. 

" axioms of, 80. 

" brain, 87. 

" causes of, 79. 

" coexistence of, 80. 

'* deglutition, 110. 

" differentiation of, 79. 

" endocardial, 78. 

" extraperi cardial, 81. 

" hsemic, 80. 

" inorganic, 79, 80. 

" of Kronicker and Meltzer, 

106. 

" organic, 79. 

" pericardial, 82. 

" subclavian, 87. 

" tabular view of, 81. 

u thyroid, 87. 

" venous, 89. 

Muscles, diseases of, 221. 

" of expiration, 33. 

" of inspiration, 13. 
Muscular atrophy, 221. 

u " lesion of, 164. 

Mycelia, 190. 
Myelitis, acute, 209. 



266 



INDEX. 



Myelitis, compression, 210. 
Myopathic paralysis, 218, 219. 
Myosis, 173. 

Myotonia congenita, 221. 
Misophobia, 200. 
Mytilotoxin, 253. 
Myxedema, 221. 

Neisser's method, 193. 
Nerves, cranial, 166. 
" spinal, 167. 
Nervous anaeidity, 241, 242. 

" belching, 241. 

" diseases, diagnosis of, 208, 
et seq. 

" " instantaneous diag- 

nosis of, 180. 

*' " functional, 214, etseq. 

u dyspepsia, 115. 

" system, 160. 

" u anatomy of, 160. 

u " physiology of, 160. 

Neuralgia, 170. 
Neurasthenia, 215. 
Neuritis, 208. 

" multiple, 208. 
Neuroses, gastric, 241, 242. 

" traumatic, 216. 

New method of auscultation, 247. 24S, 
Night sweats, 7. 
Nitrite of amyl diagnosis, 244. 
Nylander's test for sugar, 153. 
Nystagmus, 171, 172. 

o 

Obstruction, intestinal, 237. 
(Edema, with albuminuria, 8. 

tl angio neurotic, 220. 

" with cachexia, 8. 

" collateral, 8. 

" of glottis, 26. 

" with inflammation, 8, 

u of the lungs, 5. 

" malignant. 234. 
(Esophagoscopy, 105. 
(Esophagus, anatomy of, 105. 



(Esophagus, auscultation of, 106. 

" dilatation of, 106. 

" diverticulum of, 106. 

" examination of, 105. 

" narrowing of, 106. 

" new method of diagnosis 

of stenosis of, 249. 
Ohm's law, 174. 
Oidium albicans, 104, 191. 
Oligocythemia, 96. 
Oligospermia, 158. 
OligozoCspermia, 158. 
Omentum, examination of, 129. 
Ophthalmology, 182. 
Opium poisoning, 197. 

" in diagnosis, 246. 
Optic thalamus, lesion of, 164. 
Organic dementia, 204. 
Organisms in empyema, 233. 
Orthopnoea. 2. 
Ovary, cysts of, 120. 
Oxalate of lime, 64, 145. 
Oxalic acid in urine, 145. 
Oxyuris vermicularis, 187. 
Ozena, 21. 



Pachymeningitis cervicalis, 20S. 

" hemorrhagica, 211. 

Pain, sensibility to, 169. 
" spontaneous, 170. 
Palpitation of heart. 82. 
Pancreas, examination of, 129. 
Pancreatic disease, stools in, 124. 
Papular inflammation of skin, 225, 262, 
Paradox contraction, 173. 
Paradoxical pulse, SQ. 
Paresthesia, 170. 
Paralysis, 165. 

" agitans,214. 

" " diagnosis of, 180. 

" " gait in, 3. 

" " tremor of, 172. 

" Brown Sequard's, 210. 

" bulbar. 211. 

" cerebral, 213. 

" cortical, 165. 



INDEX. 



267 



Paralysis, of cranial nerves, 166, 
" diver's paralysis, 209. 
functional, 165, 218, 219. 
Landry's, 209. 
" myopathic, 218, 219. 
u of the insane, 200. 
" peripheral, 218, 219. 

11 pseudo hypertrophic, 222. 

spinal, 167, 218, r21P. 
" synoptic table of, 218, 219. 
" of vocal cords, 23. 
Paralytic dementia, 200. 

" symptoms of , 200, 

" thorax, 32. 
Paramyoclonus multiplex, 223. 
Paraplegia, gait in, 3. 

lesion of , 166. 
Parasites, animal, 184, 189. 

ll vegetable, 190. 

Parasiticides, 247. 
Paresis, general, 214. 
Parkinson's disease, 180, 214. 
Patellar reflex, 173. 
Pathogenic microbes, 229, et seq. 
Pectoriloquy, 51. 
Pediculosis, 228. 
Pediculus, capitis, 189. 
" pubis, 190. 

" vestimentorum, 190. 

Pemphigus, 224. 
Peptones, reaction for, 112. 

" in urine, 149. 

Peptonuria, 149. 
Percussion, immediate, 38. 
u of larynx, 25. 

" linear, 39. 

" mediate, 38. 

" methods of, 38. 

" palpable, 39. 

" respiratory, 39. 

" sounds of, 40. 

" topography of, 39. 

Pericardial murmurs, 81, 82. 

" thrills, 72. 

Pericarditis, 83. 
Pericardium, puncture of, 83. 
Periodical insanity, 199. 



Peripheral paralysis, 218. 
Peristaltic unreel of Btomach, 241. 
Peritoneum, diseases of, 235, et seq. 
11 examination of, l L9. 

Peritonitis. 237, 

14 subphrenic, 121. 

Perspiration. 7. 
Pertubatio critica, 13. 
Phagocytes, 192. 
Phantom tumor, 118,246. 
Phenols, tests for, 145. 
Phenomenon of lmeelli, 52. 
Phenyl hydrazin test, 153. 
Phonograph, 57. 
Phono m etry, 30. 
Phosphates, tests for, 146. 
Phtheiriasis, 228. 
Phthisical diathesis, 2. 

ulcer, 36. 
Phthisis pulmonalis, diagnosis of, 56. 

" " sputum of, 68. 

Physical signs of lungs, 53. 
Physiological crises, 202. 
Pica, 241. 
Picnometer, 142. 
Pitting, 8, 9. 
Pityriasis rubra, 225. 

" versicolor, 190, 227. 
Plasmodium malaria-, 18, 100, 230, 233. 
Plegaphony, 31. 
Pleura, friction sound of, 50. 

" puncture of, 52. 
Pleuritis, diagnosis of, 56. 

" diaphragmatic, 6. 
Pneum atom etry, 37. 
Pneumatoscope, 46. 
Pneumatosis, 241. 
Pneumococcus, 67, 230, 233. 
Pneumonia, 230. 

" diagnosis of, 55. 

" expression in, 30. 

" sputum of, 67. 

Pneumonia crouposa, 18. 
Pneumonoconiosis, 68. 
Pneumothorax, diagnosis of, 56. 
Poikilocytes, 98. 
Points, douloureux, 35. 



208 



INDEX. 



Poisoning by ptomaines, 252, 253. 
Polariscope, 154. 
Poles of galvanic current, 175. 
Poliomyelitis, 209. 

" anterior chronica, 211. 

" lesion of, 164. 

Poh T a3sthesia, 169. 
Polydipsia, 142. 
Polyneuritis, 208. 
Polyspermia, 158. 
Polyuria, 142. 
Pons varolii, lesion of, 163. 
Position, of body, 2. 

" right diagonal, 130. 
Potassium iodide in diagnosis, 244. 
Pressure murmur, 85. 

" tone, 86. 
Prickly heat, 223. 
Process of digestion, 238, 239. 
Prodromal stage, 13. 
Proglottides, 185. 
Prognosis of insanity, 204. 
Progressive muscular atrophy, 211. 
Propeptone, 149. 
Propulsion, 3. 
Prostatorrhoea, 159. 
Protozoa, 184. 
Prurigo, 225. 
Pruritis, 227. 
Pseudo-hypertrophic paralysis, 222. 

" " " gait in, 3. 

" muscular hypertrophy, 222. 
Pseudo-leucsemia, 102. 
Psoriasis, 225. 
Psorospermiasis, 237. 
Ptomaine poisoning, 252, 253. 
Ptomaines, 191. 
Ptosis, 166. 
Ptyalism, 104. 
Puerperal mania, 203. 
Pulmonary valves, diseases of, 84. 
Pulmonic anthrax, 234. 
Pulex irritans, 190. 

" penetrans, 190. 
Pulse, capillary, 85. 

" curve of, in valvular lesions, 93. 
" u of , in veins, 94. 



Pulse, dicrotic, 93. 
" frequency of, 90. 
" in diseases of heart, 91. 
" hyperdicrotic, 93. 
" monocrotic, 93. 
" paradoxical, 86. 
" pathological tracings of, 93. 
" quality of, 91. 
" rhythm of, 91. 
" senile, 91. 
" subdicrotic, 93. 
" tracing of, 92. 
" unequal size of, 91. 
Pulsus, alternans, 91. 
" bigeminus, 91. 
" celer, 91. 
" durus, 91. 
" frequens, 90. 
" irregularis, 91. 
" magnus, 91. 
" mollis, 91. 
" rams, 90. 
" tardus, 93. 
" trigeminus, 91. 
Puncta dolorosa, 35, 170. 
Pupillary reflex, 123. 
Pus, in urine, 151. 

" tests for, 151, 152, 
Pustular inflammation of skin, 224, 

225. 
Pyopneumothorax, 41. 

" subphrenicus, 42. 

Pyramidal tract, 161. 
Pyromania, 200. 
Pyuria, 151. 

Q 

Quinine in diagnosis, 245. 

R 

Railway spine, 216. 
Rales, crepitant, 49. 

" dry, 49. 

" metallic, 49. 

" moist, 49. 

" sibilant, 49. 

" sonorous, 49. 



INDKX. 



269 



Rales, subcrepitant, 50. 
Kay fungus, 67, 2:29. 
Raynaud's disease, 220. 
Reaction of degeneration, 170, 180. 
Recent methods of diagnosis, 247. 
Rectum, examination of, 118. 
Reduplication of heart tones, 78. 
Reflexes, 173. 

" of mucous membrane, 174. 
Keflex circuit, 173. 
Reflex, virile, 254. 
Regions of thorax, 28. 
Regurgitant murmur, 79. 
Relapsing fever, 17, 231. 

" " spirilla? of, 231, 232. 

Relation of stomach diseases to other 

diseases, 242. 
Reserved spaces, 45. 
Respiration, frequency of, 34. 
4 ' irregularity of, 34. 

" relation to pulse, 34. 

" types of, 33. 

Respiratory diseases, 54, et seq. 
Retroperitoneal glands, 129. 
Reuss, formula of, 120. 
Rhagades, 123. 
Rheostat, 4, 174 
Rheumatism, diagnosis of, 19. 
Rhinoliths, 139. 
Rhinoscopy, 21. 
Rickety chest, 39. 
Ring- worm, 227. 
Romberg, symptom of, 170. 
Rosenmiiller's groove, 21. 
Rumination, 242. 

S 
Salicylic acid, in diagnosis, 246. 
Saliva, 104. 
Salivary calculi, 139. 
Salivation, 104. 
Salol in diagnosis, 246. 
Saprophytes, 192. 
Sarcinse, 65, 114, 116. 
Sarcoptes hominis, 189. 
Sarkin, 145. 
Scabies, 227. 



Scarlatina (Scarlet fever,, 11. 
Schizomycetes, I'd. 
Schottelius, method of, L28. 
Scleroderma, 226. 
Sclerosis, insular, 214. 
lateral, 209. 
Scoliosis, 31. 
Sell nil richer, 126. 
Semen, 158. 
Senile dementia, 200. 
Senility, 203. 
Sensation, delay of, 169. 
Sense, of locality, 168. 
" of pain, 169. 
'' of pressure, 169. 
" of temperature, 169. 
" of touch, 168. 
Sensibility, electro-cutaneous, 169. 

" testing of, 168. 

Shingles, 223. 
Singultus, 121. 
Skin, atrophy of pigment, 227. 

" bullous inflammation of, 224. 

" changes in color, 4. 

" " in temperature, 4. 

" diagnosis of diseases of, 223. 

M emphysema of, 9. 

" erythematous inflammation of, 
223. 

" grayish discoloration of, 7. 

" hypertrophy of, 226. 

" neurosis of, 227. 

" cedema of, 7. 

" papular inflammation of, 225, 
226. 

" parasites of, 227. 

" pustular inflammation of, 224. 
225. 

" scaly inflammation of, 225. 

" temperature of, 9. 

" vesicular inflammation of, 223. 
Small -pox, 14. 
Smegma bacillus, 234. 
Snuffles, 22. 
Somnambulism, 198. 
Sopor, 197. 
Sound, metallic, 41. 



.:::) 



INDEX. 



Sound, oesophageal, 105, 106. 

' ' tympanitic, 41, 42. 
Sounds of heart, 76. 
Spasms, clonic, 170. 

" tonic, 170. 
Spastic paraplegia, 209. 
Spectroscopical examination, 96. 
Spermatozoa, 157, 158. 
Sphygmography, 92, et seq. 
Spinal cord, anatomy of, 163. 

" " diseases of, 208, et seq. 
" lesions, 164. 
" localization, 206, 207. 
" nerves, paralysis of, 167. 
" paralysis, 218. 
Spirals of Curschmann, 64. 
Spirillum of relapsing fever, 11, 99, 

231, 232. 
Spirochaete Obermaierii, 99, 231. 
Spirometry, 37. 
Spleen, anatomy of, 129. 
" auscultation of, 132. 
' ' examination of, 129, et seq. 
" inspection of, 130. 
" palpation of, 130. 
" percussion of, 131. 
Sputum, coctum, 68. 
" color, 61. 
" consistency of, .61. 
" crudum, 68. 
" micro-organisms of, 65. 
" microscopy of, 62. 
" odor of, 61. 
" origin of, 61. 
" quantity of, 61. 
" reaction of, 62. 
" in respiratory diseases, 67. 
" varieties of, 62. 
Stadium decrementi, 13. 
" incrementi, 13. 
Staining, of bacteria, 193. 

" Gram's method, 193. 
Staphylococci, 192. 

Staphylococcus pyogenes aureus, 231. 
Stenosis of oesophagus, 249. 
Stethometry, 37. 
Stethoscope, 46. 



Sthenic fever, 13. 
Stigmata, hysterical, 202. 
Stomach, absorptive power of, 113. 

" anatomy of, 107. 

" auscultation of, 110. 

" chemical analysis of, 110, et 
seq. 

" dilatation of, 108. 

" diseases of, 114. 

" diseases of, in relation to 
other diseases, 242. 

" inspection and palpation of, 
107. 

" motor activity of, 108. 

" organic acids of, 112. 

11 percussion of, 109. 

" peristaltic action of, 108. 

" " unrest of, 224. 

" thickening of, 108. 

' ' topography of, 107. 

" tumors of, 108. 
Stool, clayey, 6. 
Strassburg, method of, 151. 
Strawberry tongue, 104. 
Streptococci, 192. 
Streptococcus erysipelatis, 231, 233. 

" pyogenes, 231. 

Stridulous respiration, 60. 
Stupor, 197. 

Subnormal temperature, 10. 
Subphrenic abscess, 42, 121. 
Subsultus tendinum, 13. 
Succinic acid, 187. 
Succussion, 52. 
Sugar, tests for, 152, et seq. 

" in urine, 152. 
Sulphates, tests for, 147. 
Sulphocyanide of potassium, 104. 
Sulphuretted hydrogen, 155. 
Sulphuric acid in urine, 146. 
Sunstroke, 221. 
Suppuration, 231. 
Sweat, changes of, 7. 
Sycosis, 190. 

" simple, 224. 
" tinea, 225. 
Symmetrical gangrene, 220. 



INDEX. 



% ] I 



Syphilis, 204, 231. 

bacillus of, 103, 231, 284. 

" cause of hemiplegia, 166. 

u cerebral, 204. 

44 eye in, 183. 

44 of larynx, 20. 

14 teeth in, 103. 
Sypliilophobia, 204. 
Syringo-myelia, 210. 

T 

Tabes dorsalis, 210. 

44 u ataxia of, 168. 

44 " diagnosis of, 180. 

44 " eye in, 182. 

44 " gait in, 3. 

44 " lesion of, 104. 

Tachycardia, 90, 91. 
Taenia, echinococcus, 186. 
44 latus, 186. 
44 medio canellata, 186. 
41 saginata, 186. 
44 solium, 186. 
Tanret's method, 149. 
Tape-worm, 185. 
Teeth, 103. 

41 time of appearance of, 104. 
Teichmann's test, 95. 
Temperature in cerebro-spinal menin- 
gitis, 19. 
44 classification of, 12. 

4 ' in croupous pneumonia , 

18. 
" " diphtheria, 19. 

44 " erysipelas, 18. 

14 " malaria, 17. 

44 " measles, 13. 

44 method of examination, 

10. 
44 in miliary tuberculosis, 

19. 
44 4 ' relapsing fever, 17. 

44 " rheumatism, 19. 

44 scales of, 10. 

44 in scarlatina, 14. 

44 ' 4 small pox, 14. 

44 subnormal, 19. 



Temperature, in syphilis, 20. 

" k ' typhoid fever, L6. 

44 l * typhus fever, 16. 

44 ik varicella, L5. 

u " varioloid, r>. 

Tenderness, of vertebra 1 , 200. 
Terminal dementia, 200. 
Tetanin, 191. 
Tetanus, 231. 

bacillus of, 281. 
Tetany, 119, 214. 

44 diagnosis of, 180. 
Tetter, 223. 
Thermic fever, 221. 
Thermo-palpation, 31. 
Thoma-Zeiss apparatus, 96. 
Thomsen's disease, 171, 221. 

" " diagnosis of, 181. 

Thorax, lines of, 28. 
14 paralytic, 32. 
44 regions of, 28. 
Thrills, tables of, 72. 
Throat, anaesthesia, 105. 
Thrombosis of cerebral veins, 213. 
Thrush, 104. 
Thymus gland, 52. 
Tic convulsif, 214. 
Tinea favus, 228. 

44 sycosis, 225. 

44 tricophytina, 227. 

" versicolor, 227. 
Tones of heart, 76. 
Tongue, 104. 
Tonic spasms, 170. 
Tonsils, 104. 

Topography of brain, 205. 
Torula cerevisiae, 158. 
Tourette's disease, 217. 
Trance, 198. 

Transillumination for diagnosis, 253. 
Transudation, 120. 
Traube, space of, 41. 
Traumatic neuroses, 210. 
Tremor, 172. 
Trichina spiralis, 188. 
Trichinosis, 188. 
Tricocephalus dispar, 187, 



272 



INDEX. 



Trichomonas intestinalis, 184. 
Tricophyton tonsurans, 190. 
Tricuspid regurgitation, 84. 

" stenosis, 84. 

" valves, auscultation of, 76. 
Triple phosphates, 146. 
Trismus, 171. 
Trommer's test, 152. 
Trophic diseases, 220. 
Trousseau's sign, 171. ] 
Tubercle bacilli, staining of, 65. 

" " in urine, 158. 

Tuberculosis, 232. 

" acute miliary, 19. 

" bacillus of, 65, 232, 

234. 
" eye in, 182. 

" of larynx, 2, 6. 

" sputum in, 68. 

Tuberculous meningitis, 212. 
Tumors, of brain, 213. 
faecal, 118. 

" of intestines, 118. 

" of kidney, 134. 

" phantom, 118. 

" spleen, 130. 

" stomach, 100, 114. 
Tiirck, columns of, 163. 
Types of fever, 12. 
Typhlitis stercoralis, 237. 
Typhoid fever, 3, 16, 123, 232. 

" " bacillus of, 232. 

" " diazo reaction of, 154. 

" u stools in, 124. 

Typhoid bacilli, 232. 
Typhus abdominalis, bacilli of, 123. 

u fever, 16. 
Typus inversus, 12, 19, 
Tyrosin, 153. 
Tyrotoxicon, 253. 

u 

Ulcer, intestinal, 236. 
Urea, tests for, 143, 144. 
Uraemia, 100, 144, 197. 
" vomit in, 117 
Ureometer, 144. 



Ureters, examination of, 134. 
Uric acid, in blood, 100. 

" " test for, 144. 
Uridrosis, 7. 
Urine, abnormal constituents of, 147. 

" albumen in, 147. 

" bile in, 150. 

" blood in, 150. 

" calculi of, 138. 

" casts of, 156. 

" color of, 141. 

11 drugs in, 141, 158. 

11 examination of, 139, et seq. 

11 fibrine in, 149. 

" micro-organisms of, 157, 158. 

" mucin in, 149. 

" normal, 140. 

" normal constituents of, 143, 
145. 

" odor of, 143. 

" organic sediments of, 155. 

" pus in, 151. 

" quantity of, 142. 

" reaction of, 140. 

" specific gravity of, 142. 

" sugar in, 152. 

" synopsis of, 158. 

" transparency of, 142. 
Urobilin, 141. 

11 tests for, 141. 
Uromelanin, 142. 
Urostealith calculi, 138. 
Uroxanthin, 141. 
Urticaria, 223. 

V 

Valves of heart, 76. 

" " " table of, 76. 
Varicella, 15. 
Variola, 14. 
Varioloid, 15. 
Vaso-motor and trophic diseases, 220, 

et seq. 
Veins, auscultation of, 89. 

" distension of, 88. 

" examination of, 85. 

" pulsations of, 88. 



INDEX. 



Veins, pulse curve of, 04. 

Venous pulse, 89. 

Vermiform appendix, 11?. 

Vertebra] tenderness, clinical value 

of, 260. 
Vertigo, 197. 
Vesicular inflammation of skin, 223. 

murmur, 47. 
Virile reflex, 254. 
Vocal cords, paralysis of, 23, 24. 

k - fremitus. 3(5. 
resonance, 51. 
Voice, 23. 

" auscultation of, 51. 

" metallic sound of, 51. 

" whispered, 51. 
Volt, 174. 
Vomit, examination of, 115, et seq. 

" odor of, 117. 

11 reaction of, 117. 
Vomiting, 115. 

4 ' forms of, 115. 

Vomitus matutinus, 115. 
Voussure, 09. 

w 

Wandering kidney, 134. 



Wandering spleen, L31 

liv.r, 12& 

Weil's disease, 6, 

Whip-worm, L87. 
Whispered voice, 51. 
Whooping cough, 60. 
Wintrich, 4o. 

Wool-sorter's disease, - ; ji. 
Worms, flat, 184. 
hook, 188. 
" round, 184. 
thread, 187. 
" whip, 187. 
Writer's cramp, 171, 22:2. 



Xanthin, 145. 

" calculi of, 138. 
test for, 139. 



Yeast plant, 158. 



Zeiss, 196. 



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